Nokea
The nurse is obtaining a history on a client just admitted to the unit. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential.
Which of the following responses by the nurse is BEST?
- A. I'll share any information you give me with staff members only with your approval.'
- B. If the information you share is important to your care, I'll need to share it with the staff.'
- C. We can keep the information just between the two of us.'
- D. I have an obligation to maintain nurse/patient confidentiality about anything you tell me.'
Correct Answer: B
Rationale: Strategy: Think about the outcome of each answer choice. (1) the nurse has the obligation to share client information with personnel directly involved with the client's care (2) correct-the nurse is obligated to share client information with personnel directly involved with the client's care (3) the nurse must never agree to keep information confidential without knowing the content of the information (4) the nurse not obligated to report information that is not relevant to the client's care or wellbeing
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After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain
The nurse is caring for a postoperative patient. Four hours after surgery, the patient voids 200 cc of urine with a specific gravity of 1.019. The nurse should
- A. palpate the patient's lower abdomen for distention.
- B. encourage an increased intake of oral fluids.
- C. record the time and the amount of urine.
- D. encourage the patient to void again in two hours.
Correct Answer: C
Rationale: amount and specific gravity normal (1.010-1.030)
The nurse is obtaining a health history on a client in the medical clinic. The client states, 'I think I have an ulcer.' Which of the following responses by the nurse is BEST?
- A. Do you have a burning pain in the epigastric region?
- B. Do you have sharp pain in your lower abdomen?
- C. Do you have right shoulder pain with vomiting?
- D. Do you have heartburn when you lie down?
Correct Answer: A
Rationale: Burning epigastric pain is a classic ulcer symptom, guiding further assessment. Options B, C, and D suggest other conditions.
The neonatal nurse is instructing the family of a newborn about an apnea monitor.
The nurse should be MOST concerned if a family member makes which of the following statements?
- A. We will be able to leave our baby for brief periods of time.'
- B. We plan to sleep by our baby's crib.'
- C. We can remove the monitor during our baby's bath.'
- D. A family member will closely watch the monitor all the time.'
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates that you are looking for an incorrect statement. (1) appropriate behavior (2) appropriate behavior (3) appropriate behavior (4) correct-indicates a feeling that monitor may not let them know if their infant stops breathing
The nurse is preparing to suction a client with a new tracheostomy in the postanesthesia recovery room. Which of the following actions, if performed by the nurse, indicates a break in proper technique?
- A. The nurse sets the suction source at 120 mm Hg and obtains a #14 French suction catheter.
- B. The nurse inserts the suction catheter until resistance is met, and then applies intermittent suction as the catheter is withdrawn.
- C. The nurse suctions the client's mouth prior to suctioning the tracheostomy to ensure a patent airway.
- D. The nurse administers oxygen to the client using an Ambu bag attached to 100% oxygen prior to suctioning.
Correct Answer: C
Rationale: break in sterile procedure, suction mouth after trachea