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The nurse working in the emergency department is caring for a client with carbon monoxide poisoning. Which of the following would be the priority action to treat this condition?
- A. Initiate continuous pulse oximetry monitoring
- B. Administer high-flow oxygen
- C. Insert a peripheral vascular access device
- D. Obtain a 12-lead electrocardiogram (ECG)
Correct Answer: B
Rationale: High-flow oxygen (B) is the priority for carbon monoxide poisoning to displace CO from hemoglobin, per ACLS guidelines. Pulse oximetry (A) is unreliable in CO poisoning, IV access (C) and ECG (D) are secondary to oxygenation.
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The registered nurse (RN) observes licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply.
- A. Irrigates an indwelling catheter with warm tap water.
- B. Administers glargine insulin for a client with nothing by mouth (NPO) status.
- C. Obtains a 12-lead electrocardiogram for a client with hyperkalemia.
- D. Clamps a chest tube while the client ambulates.
- E. Repositions a client who requires log rolling by using a gait belt.
Correct Answer: A, B, D, E
Rationale: Irrigating with tap water (A) risks infection, insulin for NPO client (B) risks hypoglycemia without RN assessment, clamping a chest tube (D) risks pneumothorax, and using a gait belt for log rolling (E) is incorrect technique. ECG (C) is within LPN scope.
The most frequent threat to technological and information security in a healthcare facility is which of the following?
- A. Computer hacking by a foreign country
- B. Computer hacking by a United States citizen for ransom
- C. Failure of employees to log off computer systems and sharing of passwords with others
- D. A major electrical failure in the facility
Correct Answer: C
Rationale: Failure to log off or sharing passwords (C) is the most common security threat, as it allows unauthorized access to protected health information. Hacking (A, B) is less frequent, and electrical failure (D) impacts operations but not information security directly.
The nurse is conducting a staff education program about hand-off reports for clients in an acute care environment. Which of the following should be included during the hand-off report? Select all that apply.
- A. emergency code status
- B. allergies
- C. home medications
- D. admitting diagnosis
- E. review of previous hospitalizations
- F. health insurance status
Correct Answer: A, B, C, D
Rationale: Code status (A), allergies (B), home medications (C), and admitting diagnosis (D) are critical for safe care transitions per ISBAR standards. Previous hospitalizations (E) and insurance status (F) are not essential for immediate handoff.
The nurse is caring for assigned clients. After administering prescribed medications, the nurse should immediately intervene if the client reports
- A. nausea during an infusion of amphotericin B.
- B. palpitations after receiving rapid-acting insulin.
- C. drowsiness after receiving fentanyl.
- D. itching in the perineal area while receiving intravenous dexamethasone.
Correct Answer: B
Rationale: Palpitations after rapid-acting insulin (B) suggest hypoglycemia or an adverse reaction, requiring immediate intervention to assess and stabilize. Nausea with amphotericin B (A), drowsiness with fentanyl (C), and itching with dexamethasone (D) are expected side effects and less urgent.
The nurse has attended a staff education program about sources of negligent lawsuits. It would indicate effective understanding if the nurse identifies which of the following is a source of a negligent lawsuit?
- A. The nurse documents care under another nurse's username and password
- B. The nurse takes pictures of a client's medical record and distributes them online
- C. The nurse does not notify the physician of a client's critical laboratory result
- D. The nurse treats their spouse in the acute care facility with prescribed medications
Correct Answer: A, B, C, D
Rationale: All options (A, B, C, D) are sources of negligent lawsuits: documenting under another’s credentials (A) is fraudulent, sharing medical records online (B) violates HIPAA, failing to report critical results (C) delays care, and treating a spouse with medications (D) breaches professional boundaries and scope of practice. Since the question implies multiple selections, all are correct.