Nokea
The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.
- A. A visitor talking in the waiting room states that the client has alcoholism
- B. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home
- C. The nursing assistant tells a client that the hospital roommate went for a gallbladder test
- D. The registered nurse tells a visitor to wear a mask because the client is on isolation precautions
- E. Two LPNs are discussing a possible cure for AIDS on a crowded elevator
Correct Answer: A,B,C
Rationale: Visitor disclosure , taking reports home , and sharing roommate info violate confidentiality. Isolation precautions and general discussion do not.
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The nurse is talking with the parent of a 5-year-old client about managing recurrent nosebleeds at home. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Apply direct pressure by pinching your child's nostrils together for 5-15 minutes.
- B. Take your child to the emergency department as soon as possible.
- C. Tell your child to lie down and turn your child on the left side.
- D. Provide reassurance to keep your child calm and quiet.
- E. Place a cold cloth over the bridge of your child's nose.
Correct Answer: A,D,E
Rationale: Pressure , reassurance , and cold cloth control bleeding and anxiety. ED visits are unnecessary for recurrent nosebleeds, and lying down risks aspiration.
A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should reinforce teaching to the client on what possible adverse effect?
- A. Hypernatremia
- B. Sexual dysfunction
- C. Urinary retention
- D. Weight loss
Correct Answer: B
Rationale: Sertraline commonly causes sexual dysfunction, a significant side effect. Hypernatremia , urinary retention , and weight loss are less common.
The nurse is caring for a client who is receiving an intravenous infusion. Which finding would indicate that the client's IV has infiltrated?
- A. The client's arm is red and warm to the touch.
- B. The IV is running faster than the desired rate.
- C. The area around the infusion site is pale and cool to the touch.
- D. The client complains of severe pain up and down the arm.
Correct Answer: C
Rationale: Infiltration causes pale, cool skin around the IV site due to fluid leakage into tissues. Redness, fast infusion, or radiating pain suggest other issues.
The nurse is caring for a client who has a prescription for furosemide 1 mg/kg PO every 8 hours. The client weighs 44 lb (20 kg). The nurse has furosemide oral solution 10 mg/mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: Dose: 1 mg/kg × 20 kg = 20 mg. Solution: 20 mg ÷ 10 mg/mL = 2 mL .
An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse?
- A. I understand your desire to leave, but it would be very risky.
- B. I will ask the palliative care nurse to talk with you to help clarify your care goals.
- C. I will let the HCP know that you want to be discharged and do everything I can to make it happen.
- D. Tell me more about your need to leave the hospital.
Correct Answer: D
Rationale: Exploring the client's reasons respects autonomy and facilitates understanding. Warning about risks may dismiss feelings, referring to palliative care is premature, and promising discharge bypasses collaboration.