Nokea
Which one of the following rights is included in the Patient's Bill of Rights?
- A. The right to expect reasonable continuity of care
- B. The right to complete privacy
- C. The right to confidentiality
- D. The right to advanced directives concerning treatment
Correct Answer: C
Rationale: The Patient's Bill of Rights includes the right to confidentiality. Continuity, privacy, and advance directives are important but not explicitly listed as primary rights.
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The LPN/LVN is caring for an adult who has pneumonia. The nurse should instruct the nursing assistant to report which information immediately?
- A. Restlessness
- B. Pink-colored skin
- C. Nonproductive cough
- D. Dry mouth
Correct Answer: A
Rationale: Restlessness may indicate hypoxia in pneumonia, a critical symptom requiring immediate reporting to assess oxygenation status.
The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, the nurse should understand that adolescents with hemophilia
- A. Must have structured activities
- B. Often take part in active sports
- C. Explain limitations to peers
- D. Avoid risks after bleeding episodes
Correct Answer: B
Rationale: Often take part in active sports. Adolescents with hemophilia may engage in sports, requiring careful monitoring to prevent bleeding.
A client with a perforated bowel secondary to a bowel obstruction.
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
- A. Maintain the client in a supine position.
- B. Notify the client's next-of-kin.
- C. Prepare the client for emergency surgery.
- D. Remove the nasogastric tube.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
- A. Anxiety, unconscious anger, and hostility
- B. Guilt, indecisiveness, poor self-concept
- C. Psychomotor retardation or agitation
- D. Meticulous attention to grooming and hygiene
Correct Answer: C
Rationale: Psychomotor retardation or agitation. These are common physiologic symptoms of depression.
The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following laboratory results should the nurse report immediately?
- A. Blood glucose of 200 mg/dL.
- B. Potassium 3.0 mEq/L.
- C. pH of 7.30.
- D. Sodium 135 mEq/L.
Correct Answer: B
Rationale: Hypokalemia (3.0 mEq/L) risks arrhythmias during insulin therapy for DKA. Options A, C, and D are less urgent.