Nokea
The nurse is performing an admission for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet drug, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect requiring attention.
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The nurse is at the nurses' station charting when a physician comes up and says, 'Since you are already logged into the computer, I need you to look up some labs on a client.' The client is not cared for by this nurse. Which response by the nurse is most appropriate?
- A. Let me check that for you in a moment.
- B. Why don't you call the lab? That will be quicker.
- C. That is not my client, but I will get his nurse for you.
- D. I can't do that because of HIPAA, but I will let the charge nurse look it up.
Correct Answer: D
Rationale: Accessing a client's lab results without authorization violates HIPAA, as the nurse is not assigned to the client. The charge nurse can ensure proper access.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
- A. Dulcolax suppository
- B. Docusate sodium (Colace)
- C. Methyergonovine maleate (Methergine)
- D. Bromocriptine sulfate (Parlodel)
Correct Answer: B
Rationale: Docusate sodium (Colace) is a stool softener, appropriate to prevent straining and promote healing after a proctoepisiotomy.
The nurse has documented a treatment on the wrong client's record. Which of the following methods of indicating the error is correct?
- A. The nurse draws a straight line through the incorrect entry and writes 'error' above it and initials the correction.
- B. The nurse uses correction fluid to cover the incorrect entry.
- C. The nurse draws multiple lines through the incorrect entry so it is unreadable, writes 'error' above it, and initials the correction.
- D. The nurse leaves the incorrect entry in place, writes 'error' in the margin, and initials and dates the notation.
Correct Answer: A
Rationale: A single line through the error with 'error' written above and initialed (A) maintains transparency while correcting the record. Correction fluid (B) is unacceptable, multiple lines (C) obscure the record, and margin notes (D) are insufficient.
The nurse is caring for a group of clients in an alcohol rehabilitation facility. A local news station is doing a story on addiction, and a representative comes to the facility, asking to interview a client. A client agrees to appear in the story, and the crew films an interview in the dayroom, showing a glimpse of other clients. Which violation has the nurse committed?
- A. allowing clients in a substance abuse facility to be interviewed by the media
- B. violating the HIPAA need to know rule
- C. releasing information about a minor without parental consent
- D. There is no violation.
Correct Answer: B
Rationale: The nurse violated HIPAA by allowing the filming of other clients without their consent, as this discloses protected health information (PHI) without authorization.
The nurse is caring for a client who will have a pulmonary function test (PFT) performed as an outpatient following hospital discharge. Which should the nurse include in his teaching on the procedure? Select all that apply.
- A. have a driver accompany the client to the test site
- B. limit activity in the days leading up to the test
- C. remain NPO after midnight the day before the test
- D. do not smoke for at least 6-8 hours before the test
- E. withhold bronchodilators for 4-6 hours prior to the test
- F. increase aerobic activity as much as possible in the days before the test
Correct Answer: D,E
Rationale: Smoking cessation for 6-8 hours and withholding bronchodilators for 4-6 hours ensure accurate PFT results. Other instructions are unnecessary or incorrect.