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The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?
- A. Send an email to facility administrators reporting the action.
- B. Dispose of the copies and continue with client care assignments.
- C. Warn the colleague that copying health information is unlawful.
- D. Communicate the colleague’s activities to the unit charge nurse.
Correct Answer: D
Rationale: Reporting ensures intervention.
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The client had a large, loose stool.
Vital signs: Temperature 98.7°F (37°C) orally. Heart rate 73 beats/minute.
Blood pressure 144/82 mm Hg. The client had a large, loose stool. The client had a large, loose stool.
Place the client on contact precautions.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take, and two parameters to assess the client’s progress.
- A. Collect stool for culture, Start a high-fiber diet., Administer an oral steroid.,Make the client NPO
- B. Secretory diarrhea.Steatorrhea,Motility diarrhea,Osmotic diarrhea
- C. Heart rate, Serum potassium,Respiratory rate, Urine sodium
Correct Answer:
Rationale: Secretory diarrhea fits; stool culture and NPO address infection; heart rate and potassium monitor dehydration.
A family requested a visit from a hospice nurse as they think the client appears to be nearing the end of life. The nurse assesses the client. Which of the following signs indicate that the client is near death?
- A. Decreased muscle tone, relaxed jaw muscles, sagging mouth.
- B. Urine output is clear yellow.
- C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern).
- D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).
Correct Answer: A,C,D
Rationale: Muscle tone, breathing, and secretions indicate nearing death.
A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?
- A. Remove dentures or other oral appliance.
- B. Elevate the head of the bed to a 45-degree angle.
- C. Apply the client’s positive airway pressure device.
- D. Put and lock the side rails in place.
Correct Answer: C
Rationale: CPAP prevents airway collapse.
A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?
- A. Place the client on contact precautions.
- B. Start a high-fiber diet.
- C. Administer an oral steroid.
- D. Make the client NPO.
Correct Answer: D
Rationale: Follow regular diet per orders.
The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
- A. 2+ edema of fingers and hands.
- B. Capillary refill time is 2 seconds.
- C. Blood pressure is 142/88 mm Hg.
- D. Radial pulse volume is 3+.
Correct Answer: A
Rationale: Edema distorts oximeter readings.