Nokea
The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?
- A. Rubber-free toys, such as wooden building blocks, are good choices for the child.
- B. Only foil balloons will be used for the child's birthday party.
- C. A diet of healthy fruits, such as bananas and kiwis, is best for the child.
- D. An epinephrine auto-injector will be on hand to treat allergic reactions.
Correct Answer: C
Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.
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After receiving change-of-shift report, which patient should the nurse assess first?
- A. Patient with a serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
- B. Patient with a serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
- C. Patient with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
- D. Patient with a serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
Correct Answer: C
Rationale: The correct answer is patient C with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures, which are life-threatening. Assessing and addressing this patient's condition promptly is crucial to prevent complications. Patients A, B, and D have mild electrolyte disturbances or symptoms that require attention, but they are not at immediate risk for life-threatening complications like seizures, unlike patient C.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
- A. Discontinue the nasogastric suction.
- B. Give the patient the PRN IV morphine sulfate 4 mg.
- C. Notify the health care provider about the ABG results.
- D. Teach the patient how to take slow, deep breaths when anxious.
Correct Answer: B
Rationale: The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.
The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague's assignment. Which action should the nurse implement?
- A. Communicate the colleague's actions to the unit charge nurse
- B. Send an email to facility administration reporting the action
- C. Write an anonymous complaint to a professional website
- D. Post a comment about the action on a staff discussion board
Correct Answer: A
Rationale: Viewing the EHR of a client who is not under your care is a violation of HIPAA regulations, regardless of the client's social status or your curiosity. The appropriate action to take in this situation is to communicate the colleague's actions to the unit charge nurse. The charge nurse can then escalate the issue through the appropriate channels within the organization. Reporting to the charge nurse ensures that the incident is handled internally and in accordance with organizational policies and procedures. Sending an email to facility administration, writing an anonymous complaint to a professional website, or posting a comment on a staff discussion board are not the recommended actions as they may not address the issue effectively and could potentially violate confidentiality further.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
- A. Increase fluids if your mouth feels dry.
- B. More fluids are needed if you feel thirsty.
- C. Drink more fluids in the late evening hours.
- D. If you feel lethargic or confused, you need more to drink.
Correct Answer: A
Rationale: The correct answer is A. An alert, older patient can self-assess for signs of dehydration like dry mouth. This instruction is appropriate as it encourages the patient to respond to early signs of dehydration. Choice B is incorrect because the thirst mechanism decreases with age and feeling thirsty may not accurately indicate the need for fluids. Choice C is incorrect as many older patients prefer to limit evening fluid intake to enhance sleep quality. Choice D is incorrect because an older adult who is lethargic or confused may not be able to accurately assess their need for fluids.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
- A. I will try to drink at least 8 glasses of water every day.
- B. I will use a salt substitute to decrease my sodium intake.
- C. I will increase my intake of potassium-containing foods.
- D. I will drink apple juice instead of orange juice for breakfast.
Correct Answer: D
Rationale: The correct answer is D. Spironolactone is a potassium-sparing diuretic, so patients should choose low-potassium foods. Apple juice is a better choice than orange juice in this case as it is lower in potassium. Option A is incorrect because increasing fluid intake excessively is not necessary. Option B is incorrect as salt substitutes are high in potassium, which should be avoided. Option C is incorrect because patients on spironolactone should avoid increasing their potassium intake.