Nokea
The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN?
- A. The patient states she feels the need to urinate.
- B. Patient reports a pinching sensation as the catheter is advanced.
- C. The student nurse notes resistance when inflating the balloon.
- D. The student separates the labia majora and labia minora with non-dominant hand.
Correct Answer: C
Rationale: Resistance when inflating the catheter balloon (C) suggests improper placement (e.g., in urethra), risking trauma, requiring immediate RN intervention. Urge to urinate (A) and pinching (B) are normal, and labia separation (D) is correct technique.
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The nurse approached a client with a blood pressure cuff, and the client extended their arm to allow the nurse to obtain a reading. The nurse understands that this exemplifies what type of consent?
- A. Informed consent
- B. Implied consent
- C. Expressive consent
- D. Written consent
Correct Answer: B
Rationale: Extending an arm for a blood pressure reading (B) is implied consent, as the client’s action indicates agreement. Informed consent (A) requires explanation, expressive consent (C) is not a standard term, and written consent (D) is for procedures.
The nurse working on a medical-surgical unit has just received a change-of-shift report. The nurse should initially assess the client who is
- A. receiving treatment for chronic pulmonary emphysema with PaCO2 of 50 mm Hg.
- B. admitted with pulmonary tuberculosis (TB) and refuses their prescribed isoniazid.
- C. infected with Clostridium difficile, and is reporting dizziness.
- D. being treated for acute pyelonephritis and has a temperature of 101.8°F (38.7°C).
Correct Answer: C
Rationale: Dizziness with Clostridium difficile infection (C) suggests dehydration or electrolyte imbalance, which can lead to falls or cardiovascular instability, requiring immediate assessment. A PaCO2 of 50 mm Hg in chronic emphysema (A) is often a baseline finding, TB medication refusal (B) is concerning but not immediately life-threatening, and fever in pyelonephritis (D) is expected and less urgent than acute instability.
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
- A. A client with a blood glucose of 250 mg/dL [70–100 mg/dL, 4.0–5.6 mmol/L] who is requesting insulin coverage.
- B. A client post-thyroidectomy with a hoarse voice and difficulty speaking.
- C. A client with pneumonia reporting shortness of breath after ambulating.
- D. A client post-cholecystectomy requesting pain medication for a pain score of 7/10 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Hoarse voice and difficulty speaking post-thyroidectomy (B) suggest possible laryngeal nerve damage or hypocalcemia, life-threatening complications requiring immediate assessment. High glucose (A), shortness of breath (C), and pain (D) are less acute.
The registered nurse (RN) supervises a licensed practical/vocational nurse (LPN). Which statement by the LPN/VN requires follow-up by the RN?
- A. I bathed the client already this morning'
- B. I passed out letters and packages to the clients this morning.'
- C. The client refused his prescribed valproic acid, so I snuck it into his food.'
- D. I will be joining the clients with their games today in the day room.'
Correct Answer: C
Rationale: Hiding medication in food (C) is unethical, unsafe, and violates client autonomy, requiring immediate RN follow-up. Bathing (A), distributing mail (B), and joining games (D) are within the LPN’s scope and do not require intervention.
The nurse is conducting a staff in-service on client privacy. Which of the following actions would the nurse recognize as violations of client confidentiality? Select all that apply.
- A. Accessing a co-worker's address in their medical record to surprise them with a birthday gift.
- B. Reviewing a client's prescriptions with a student nurse who is assigned to the client.
- C. Looking up the medical information of a friend from a previous stay, even with their permission.
- D. Viewing a friend's medical record because you are listed as their power of attorney.
- E. Walking away from a computer terminal without securing it, even if the monitor is turned off.
Correct Answer: A, C, E
Rationale: Accessing a co-worker’s record for personal reasons (A), viewing a friend’s past record without current need (C), and leaving an unsecured computer (E) violate HIPAA confidentiality rules. Reviewing prescriptions with an assigned student (B) is educational, and viewing as power of attorney (D) may be authorized.