Nokea
Which nursing action(s) can result in disciplinary action by state boards of nursing?
- A. Release of client health information to a client's neighbor
- B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
- C. Release of client health information to the client's durable power of attorney
- D. A, B
Correct Answer: D
Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals like a client's neighbor (A) and improper delegation of tasks to unlicensed personnel (B) are serious violations of patient confidentiality and safety standards, which can lead to disciplinary action by state boards of nursing. Choice C, releasing client health information to the client's durable power of attorney, is not a violation as it involves sharing information with an authorized individual. Therefore, choices A and B are incorrect, making D the correct answer.
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Protecting the rights and privacy of the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: C
Rationale: The correct answer is C: Implementation. Implementation is the phase where the nursing care plan is put into action, which includes safeguarding the patient's and their family's rights and privacy. Evaluation (choice A) involves reviewing the effectiveness of the care plan, Planning (choice B) is the phase where the care plan is developed, and Assessment (choice D) is the initial step where data about the patient is collected.
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?
- A. Measuring and recording fluid intake and output
- B. Weighing the client daily at the same time each day
- C. Assessing the client's vital signs every 4 hours
- D. Checking the client's lungs for crackles during every shift
Correct Answer: B
Rationale: Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can reflect fluid retention or loss. Measuring and recording fluid intake and output (Choice A) is important but may not provide immediate changes in fluid status. Assessing vital signs (Choice C) can offer some information but may not be as specific to fluid status as daily weighing. Checking the client's lungs for crackles (Choice D) is more related to assessing respiratory status rather than direct fluid monitoring.
The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?
- A. Encourage the client to drink liquids
- B. Perform active range of motion exercises
- C. Elevate the head of the bed to 45 degrees
- D. Provide a high-fiber diet to the client
Correct Answer: B
Rationale: The correct answer is to perform active range of motion exercises. When a client is on strict bed rest, performing range of motion exercises is a priority to prevent complications such as thromboembolism and muscle atrophy. Option A may be important but not the priority compared to maintaining mobility. Option C is incorrect because elevating the head of the bed to 45 degrees is not necessary for a client on strict bed rest. Option D, providing a high-fiber diet, is also not the priority intervention compared to ensuring range of motion exercises are performed.
The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?
- A. Monitor vital signs every two (2) hours until stable
- B. Weigh the client in the same clothing at the same time daily
- C. Administer mouth care every eight (8) hours
- D. A, B, and C
Correct Answer: D
Rationale: The correct interventions for a client with fluid volume deficit include monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. Monitoring vital signs helps in early detection of changes, daily weighing can indicate fluid retention or loss, and skin turgor assessment is a reliable indicator of hydration status. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and should not be included in the plan of care for this specific condition.
The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?
- A. Deep tendon reflexes
- B. Arterial blood gases
- C. Skin turgor
- D. Capillary refill time
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes. When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Choices B, C, and D are not directly related to the assessment needed when administering magnesium sulfate in this scenario. Arterial blood gases are not typically assessed specifically for magnesium sulfate administration; skin turgor and capillary refill time are more related to hydration status and perfusion, respectively.