Nokea
The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease and pneumonia. The nurse notes that the client has become disoriented and restless and becomes concerned that the client may have impaired oxygenation due to poor secretion clearance. Which is the nurse’s priority action?
- A. Administer lorazepam 1 mg IM
- B. Administer oxygen using venturi mask
- C. Maintain IV normal saline infusion at prescribed rate of 125 mL/hr
- D. Place the head of the bed in semi-Fowler position
Correct Answer: B
Rationale: Disorientation and restlessness suggest hypoxia. Administering oxygen via a venturi mask delivers precise oxygen concentrations to improve oxygenation, addressing the priority concern. Lorazepam may worsen respiratory depression, IV fluids do not address hypoxia, and semi-Fowler aids breathing but is secondary.
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Which information should be included in the nurse's shift report?
- A. The client's sodium level is 147 mEq/L
- B. The client's potassium level is 4 mEq/liter
- C. The client's urine output was 1500 cc in 5 hours
- D. The client is to receive another dose of Lasix at 10 PM
Correct Answer: C
Rationale: Although all of these may be correct information to include in report, the essential piece would be the urine output, as it indicates the client's fluid status and response to treatment.
Legal protection of confidentiality:
- A. extends only to written documentation.
- B. extends to the electronic dissemination of information not identifiable to a specific client.
- C. is important only within the court system.
- D. extends to both written and verbal information.
Correct Answer: D
Rationale: Confidentiality protects both written and verbal identifiable health information to maintain client privacy. Non-identifiable data may not require protection, and confidentiality is not limited to courts. Coordinated Care
A client recovering from a head injury is receiving medication and nutritional feedings by nasogastric tube. The doctor has ordered medication to prevent seizure activity. The medication is supplied by the pharmacy in tablet form. Before administering the medication, the nurse should:
- A. Crush the medication and envelop it in a small amount of ice cream before giving.
- B. Help the client to sit upright while giving the tablet by mouth.
- C. Crush the tablet, mix in 100 ccs of tube feeding, and administer via NG tube.
- D. Ask the pharmacist if the medication is available in liquid form.
Correct Answer: D
Rationale: For NG tube administration, liquid medication is preferred to ensure proper delivery and absorption. Crushing tablets may alter efficacy, and oral administration is inappropriate.
The nurse is caring for a client diagnosed with generalized anxiety disorder. What behavior demonstrates that the client is building resilience toward improving anxiety symptoms?
- A. Avoids anxiety-producing situations
- B. Identifies anxiety-reducing triggers
- C. Practices stress-reduction techniques daily
- D. Relies on medication to manage symptoms
Correct Answer: C
Rationale: Practicing stress-reduction techniques daily, such as mindfulness or deep breathing, actively builds resilience by equipping the client with tools to manage anxiety symptoms effectively. Avoiding situations may reinforce anxiety, identifying triggers is helpful but less proactive, and relying solely on medication does not foster long-term resilience.
A wrong committed by one person against another (or against the property of another) that might result in a civil trial is:
- A. a tort.
- B. a crime.
- C. a misdemeanor.
- D. a felony.
Correct Answer: A
Rationale: A tort is a civil wrong, like negligence, that may lead to a civil trial. Crimes, including misdemeanors and felonies, are offenses against the public, often prosecuted criminally. Coordinated Care