Nokea
The nurse is admitting a new client complaining of severe abdominal pain. When asked about valuables, the client says he has $1,500 cash in his wallet. He is from out of state and does not have anyone who can take his wallet into safekeeping for him. Which statement by the nurse best addresses this situation?
- A. I can keep it locked up in the charge nurse's office for you.
- B. It should be fine. Just hide it in a drawer when you go down for a CT scan.
- C. I can call security to bring a form to fill out, and they will lock it up for you.
- D. You will have to call someone to come get it. We can't let you keep it in your room.
Correct Answer: C
Rationale: Security handling valuables follows hospital policy, ensuring safety and documentation.
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A 4-month-old infant is admitted to the pediatric unit for a 10-day course of antibiotics. The parents are only able to visit on weekends. Which action indicates the nurse understands the emotional needs of the infant?
- A. The nurse care plan calls for soothing music to be played several times per day.
- B. The nurse self-assigns care for the infant each shift worked.
- C. The nurse assigns a male nurse to care for the infant as much as possible.
- D. The nurse places the infant in a room close to the nursing station.
Correct Answer: A
Rationale: Soothing music addresses the infant's emotional needs by providing comfort in the absence of parents.
The nurse is caring for clients on a medical-surgical floor. Which tasks related to pain management can be delegated to unlicensed assistive personnel (UAP)? Select all that apply.
- A. assessing the pain level on a scale of 1-10
- B. reminding clients to report pain immediately
- C. reporting facial grimacing in unresponsive clients
- D. asking clients directly, 'Are you having any pain right now?'
- E. giving acetaminophen (Tylenol) after the nurse obtains the medication but is interrupted to attend a code blue before she administers it
Correct Answer: B,C,D
Rationale: UAPs can remind clients to report pain (B), report objective signs like grimacing (C), and ask about pain presence (D), as these tasks do not require clinical judgment. Assessing pain levels (A) requires nursing judgment, and administering medications (E) is outside the UAP's scope.
Which diagnostic tool is most commonly used to determine the location of the myocardial damage?
- A. electrocardiogram (ECG)
- B. echocardiogram
- C. cardiac enzymes
- D. cardiac catheterization
Correct Answer: A
Rationale: An ECG is the primary tool to identify the location of myocardial damage by showing characteristic waveform changes. Echocardiograms assess heart function, enzymes indicate damage but not location, and catheterization is invasive and less common initially.
A local volunteer singing group performs in the activity room of a long-term care facility. The group's leader asks the nurse if they may take a photo of themselves with several of the clients. The nurse gives permission to the leader, who then posts the photo on Facebook. Upon notification of this situation, the facility administration immediately terminates the nurse. What Health Insurance Portability and Accountability Act (HIPAA) violation did the nurse commit?
- A. breach of confidentiality
- B. failure to seek administrative approval
- C. unethical conduct
- D. unprofessional conduct
Correct Answer: A
Rationale: Allowing the photo and its public posting without consent violates client confidentiality under HIPAA.
The ED nurse is attending orientation for nurses new to working in the ED. As part of the training, the ED nurse would expect to report which conditions to the proper authorities? Select all that apply.
- A. West Nile virus
- B. herpes simplex
- C. gunshot wounds
- D. elder abuse or neglect
- E. bites from an unknown dog
Correct Answer: A,C,D,E
Rationale: West Nile virus, gunshot wounds, elder abuse, and unknown dog bites are reportable due to public health or legal mandates.