Practice one test Flashcards
The nurse is caring for a group of clients in an alcohol rehabilitation facility. A local news station is doing a story on addiction, and a representative comes to the facility, asking to interview a client. A client agrees to appear in the story, and the crew films an interview in the dayroom, showing a glimpse of other clients. Which violation has the nurse committed?
- Allowing clients in a substance abuse facility to be interviewed by the media
- violating the HIPPA need to know rule
- releasing information about minor without parental consent
- there is no violation
Number 1 is correct.
HIPPA rules do not follow clients in a substance abuse facility to be interviewed, even if the client agrees to do so. Not only was the client shown on TV, but other clients were also shown in the dayroom, which violates their right to privacy. The need to know rule applies when releasing client’s care. There is no indication in this scenario that the client is a minor.
The nurse is talking with a client who has been diagnosed with thyroid cancer. The client is asking about different treatment options. Which response by the nurse is most appropriate?
- “There are several local groups you can join after you have completed chemo”
- “Don’t worry about it. Your doctor will explain the best course of treatment for you”
- “What information has your health care provider shared about the different treatment options?”
- ” I wouldn’t take chemo if I were you. I’ve seen so many clients say that they wish they hadn’t done it “
Number 3 is correct.
Before launching a discussion, the nurse must be aware of the client’s knowledge and understanding of the different treatments. Understanding the client’s background will guide the nurse in what information to reinforce to the client or highlight areas the client may want to explore further with the health care provider. Telling the client about local support groups is helpful, but the nurse’s response implies that the client will choose chemo. Telling the client not to worry because the doctor will select the best course of treatment is belittling and also implies that the decision will be made for her, not with her. Telling the client not to take chemo is offering the nurse’s opinion, giving advice, and shuts down the opportunity for further discussion.
The nurse is working in the ED when a client in labor comes in and says that she dies not have health insurance, but wants to know if a doctor will see her. The nurse understands the clients right to emergency services, regardless of ability to pay, is provided by which piece of legislation?
- HIPPA
- the Continuity of the Care Act
- the Patient’s Bill of Rights
- the Code of Ethics for Nurses
Number 3 is correct.
The Patients Bill of Rights was adopted by the Presidents Advisory Commission on Consumer Protection and Quality in the health Care Industry. This bill states that all clients are entitled to be screened and receive stabilizing treatment from emergency services, regardless their ability to pay. HIPPA prohibits the release of private health information . There is no Continuity of Care Act. The Code of Ethics for Nurses provides guidance on professional practice based on ethical principles.
An RN is working with an LPN to care for a group of clients. Which client would the LPN would the RN most likely assign to the LPN?
- a client receiving blood following back surgery
- a client who has returned from having a left heart catheterization
- a client with an arterial line who is on nitroprusside drip to control blood pressure
- a client with an abdominal wound requiring dressing changes every 4 hours and PRN
Number 4 is correct.
The LPN can perform wound dressing changes without oversight from an RN. An LPN cannot hand blood, so the client receiving blood would not be the best assignment. Clients who had a catheterization require frequent site assessments of the puncture site, which is beyond the scope of practice of an LPN. The client on the nitroprusside drip may require titration, which is also beyond the scope of an LPN. Caring for an arterial line requires site assessment, troubleshooting and calibrating the transducer, which is an advanced RN skill.
The nurse is caring for an elderly client following a total knee replacement. The client is disoriented to time and space, and has pulled out multiple IVs. The health care provider writes an older for soft wrist restraints. Which of the following are appropriate nursing actions for this client? select all that apply
- secure restraints with a double knot
- offer toileting and nutrition every 2 hours
- ask for a new restraint order every 8 hours
- check restraints for proper placement and check the skin every 2 hours
- document the type of restraint, need for continued use, and trial release results
Numbers 2, 4, and 5 are correct.
Clients in restrains must be offered toileting and nutrition every 2 hours. Restraints should be checked every 2 hours for proper placement, and the skin assessed. Documentation of restraints includes type of restraint, the need for continues use, and the results of a trial release. Many facilities require that a trail release be performed on clients with restraints at least one per shift. Restraints should be tied with a quick release knot in case of an emergency. Restraints orders must be renewed every 24 hours, and they may not be written on a PRN basis. Follow facility guidelines when caring for restrained clients.
The nurse is in the medication room drawing up insulin for a client when a code blue is called. In his haste to respond to the call, the nurse places a syringe of insulin on the counter and responds to the code. Afterward, the nurse returns to the medication room and retrieves the syringe of insulin. Which action by the nurse is correct?
- return the insulin to the insulin vial and draw up a new syringe
- administer the insulin after labeling the syringe with the date, dose, and client name
- dispose of the syringe in the sharps container, and draw up a new dose in a new syringe
- administer the insulin that was drawn up, since the syringe is still in the medication room
Number 3 is correct.
Since the medication was left out, there is no way to be sure that it was not tampered with or contaminated; therefore, the nurse should dispose of the syringe in the sharps container and draw up a new dose of insulin. Returning the insulin to the vial increases the risk of cross contamination, since the contents of the syringe may be contaminated. Administering the insulin after labeling it still leaves the client vulnerable, since medication is unattended. Option 4 is risky because the insulin on the syringe may have been contaminated with something else. Nurses should never give medications that were drawn up and then out of their sight for any period of time. If a medication error or adverse reaction occurs, the nurse is responsible due to negligence.
The nurse is preparing to administer the first dose of the IV antibiotic to the client. Halfway through the infusion, the nurse realizes that the antibiotic dosage is not the same as ordered by the health care provider. Which action should the nurse take first?
- stop the infusion
- fill out an incident form
- notify the health care provider
- only give part of the antibiotic to obtain the correct dosage
Number 1 is correct.
The first step after discovering any medication error is to stop the infusion. The nurse should also notify the health care provider for further orders and complete an incident report. The nurse should observe the client for any signs of allergic reaction or overdose and be prepared to report to the health provider exactly how much medication infused. If the wrong dose of a medication is hung, the nurse should never try to give the ordered amount by adjusting the amount to infuse. This can cause an error and may lead to serious side effects if the client is overdosed.
The nurse is entering several orders that the health care provider has just ordered for a new admission. One of the medication orders is illegible. Which action by the nurse is corrected?
- ask another nurse to transcribe the order
- call the prescribing physician for clarification
- scan the order to the pharmacy and let the pharmacy staff decipher it
- figure it out based on the client’s diagnosis and home medications
Number 2 is correct
The nurse should always call for clarification. Asking another nurse to transcribe the order may still result in a medication error. While most medication orders are scanned to the pharmacy in facilities using computerized medication systems, the nurse still should know which medications the patient is receiving. The pharmacy may also misread the order, so the nurse should return to the source for clarification. The nurse should not attempt to guess at the medication based on the client’s diagnosis or home medications, because this may also be incorrect. The nurse has duty to clarify any unclear orders with the health care provider who wrote the orders.
A client who just delivered is concerned about her neonate’s Apgar scores of 7 at 1 minute and 8 at 5 minutes. She has been told a score lower than 9 is associated with learning disabilities. Which response is best?
- “Your infant is fine. Don’t worry”
- “Apgar scores indicate a need for extra medical care at birth. Your baby’s score of 7 is fine.”
- “There are many good special education programs available I can recommend”
- ” I’ll ask the physician to speak with you”
Number 2 is correct.
Developed in 1952 by anesthesiologist Virginia Apgar, the test rates five areas on the scale of 0-2, for a posible score of 10. The scores of 7 and 8 are considered acceptable. Response 2 provides an explanation to the client about the test while confirming the acceptability of her neonates score. It is inappropriate to tell the client not to worry. Information on a special education program is un warranted in this situation. NCLEX RN wants to know the action of the nurse in this situation, not the physician.
An elderly client’s wife tells a nurse she is concerned because her husband insists an talking about past events. The nurse assesses the client and finds him alert, oriented, and responsive to questions. Which statement should the nurse make to the client’s wife?
- “Your husband is choosing to live in a happier time in his life”
- “Redirect your husband to speak about current events when he begins regressing into the past”
- ” If he were my husband, I would call our minister to speak to him”
- ” Your husband is reflecting on his life. This is normal at his age”
Number 4 is correct
Reminiscing is a common occurrence by the elderly. The nurse should confirm this behavior with the client’s wife. Redirecting the husband to speak on current event interferes with the normal pattern of reminiscing. Stating what you would do is contraindicated when interacting with the clients wife. Additionally, this statement assumes the client’s wife is involved in organized religion.
A client who is postmenopausal asks the nurse how to prevent osteoporosis. Which statement should the nurse make to the client?
- “Eat 2 ounces of cheese each day and walk a mile a day”
- “There are no known ways to prevent osteoporosis”
- “Do weight-bearing exercises regularly and take hormones as ordered by your physician”
- “Take potassium supplements daily”
Number 3 is correct.
Hormone replacement therapy and weight-bearing exercises (such as walking) are recommended to prevent osteoporosis. A therapeutic dose of calcium to influence bone density for women 51 and older is 1,200 mg/day. two ounces of hard cheese contains 500mg of calcium, which is suboptimal. Potassium supplements are not effective in preventing osteoporosis.
The nurse is caring for a client who recently experienced a massive stroke. Which of the following statements by the spouse indicates a need for further teaching by the nurse?
- “My spouse may not return to normal for some time”
- “I plan on returning to work full time as soon as my spouse returns home”
- “Home health care will help us once my spouse is discharged”
- “You will provide me with support during this difficult time”
Number 2 is correct.
The spouse will likely need to limit her work hours at least initially to remain available to the client upon discharge. The goal of hospitalization is to return the client to maximum independence, although he may not return to normal for some time, if at all. Home health care will assist the client at home upon discharge. Nursing care involves the family as well as the client. Providing support to the client and family are within the scope of nursing practice.
The nurse is on a memory care unit. A client insists on leaving to go home. Which of the following should the nurse do?
- review the reality orientation board in the client’s room
- take the client to the activity room to interact with others
- contact the client’s primary health care provider for a medication order
- provide the client with a glass of milk and a sandwich
Number 1 is correct.
Reorienting the client to her surroundings by reviewing the reality orientation board in the room is advisable. Taking the client to a noisy room with strangers is not advisable. Obtaining an order for medication may be necessary should other activities be ineffective, but it is not the best initial intervention. Providing food and fluids would be helpful if the client is thirsty or hungry, but it is not the best initial intervention.
T
Numbers 1,3l and 4 are correct.
From an Islamic perspective, prayer time is sacred and other activities should be avoided. Food brought by family members from home is beneficial as it is prepared using Islamic traditions. Modesty and privacy are honored in the Muslim tradition where care by a staff member of the same sex is preferable. Fish killed by removal from water are considered halal (lawful) and may be eaten.
T
Number 1 is correct.
Lactated Ringer’s is typically administered in the first 24 hours because of its composition is similar to the extracurricular fluid that has shifted from damage to the skin. D10W is less ideal than lactated ringer at this time post burn as it lacks sodium, chloride, lactate, potassium and calcium. Plasma would be administered in the next 24 hours. Normal saline will not meet the fluid and the electrolyte requirements for the client at this stage in his recovery.
T
Numbers 1, 2, and 4 are correct.
Music, stretching exercises and relaxation are proven nonpharmacological pain management techniques that the nurse is able to teach the client. Therapeutic massage for the purpose of pain management is performed by a licensed massage therapist.
T
Numbers 2 and 4 are correct.
Anxiety increases sympathetic stimulation to the bowels, thereby increasing the symptoms. Reducing the anxiety will lessen the incidence of IBS episodes. The precise mechanism on how probiotics aid in IBS symptoms is not known, but it is thought to alter bacteria found in the intestines. Ingestion of cold liquids will increase intestinal mobility that is contraindicated in IBS. Further, caffeine is considered a trigger food for symptoms of IBS. Fluid intake should be increased by compensate for fluid be increased to compensate for fluid loss associated with frequent bowel elimination.
T
Number 4 is the correct.
Auditory diversional activities, such as radios and CDs, should be encouraged. Regular-size printed material will not be readable. Instead, provide the client with large size printed instructions. Stand to the side of the client when addressing her as central vision is impaired with limited acuity.
T
Number 3 is correct
Proper lighting allows the client to see your face, improving communication. In many types of hearing loss, the ability to hear higher pitched tones is lost. Unless you know the client knows sign language, this communication form will frustrate the client. Gentle touching allows the client to know where you are located.
T
Numbers 4 and 5 are correct.
Antacids interfere with absorption tetracycline, along with food, milk and milk products. Aluminum, calcium and magnesium decrease absorption of the drug. It may be taken on an empty stomach with another liquid besides milk. Grapefruit juice does not interfere with tetracycline, which should be given on an empty at least one hour before meals or two afterward. Tetracycline should be given with caution in clients with renal or liver dysfunction, and blood panels should be monitored.
T
Numbers 1, 3, and 4 are correct.
Tetanus, chlamydia and Lyme disease are designated as reportable disease are designated as reportable diseases by the CDC. Reportable diseases are considered to be a national concern due to their seriousness, the risk of death, or the ease with which they spread. Untreated tetanus can lead to laryngospasm, pneumonia, pulmonary embolism and difficulty breathing. Chlamydia can cause permanent damage to a woman’s reproductive system and may cause a potentially fatal ectopic pregnancy. Lyme disease can spread to any organ in the body and can cause permanent damage to the brain, heart and neurological system. Scarlet fever and group B streptococcal infection are not reportable under current CDC guidelines.
T
Number 4 is correct.
The first action is to notify the health care provider for further orders. The nurse should never induce vomiting, as this may cause more harm to the client. Obtaining vital signs is important but can be done after health care provider is notified. An incident report should be completed following the facility guidelines once the situation is under control and the client has been stabilized.
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
