A friend of a nurse calls and asks if she is still working at
Memorial Hospital. The nurse replies, "Yes." The friend tells the
nurse that his girlfriend's father was just admitted as a patient
and he wants the nurse to find out how he is. The friend states,
"Sue seems unusually worried about her dad, but she won't talk
to me and I want to be able to help her." What is the best initial
response the nurse should make?
A. "You shouldn't be asking me to do this. I could be fined or
even lose my job for disclosing this info."
B. "Sorry, but I'm not able to give info about patients to the
public, even when my best friend or family member asks."
C. "Because of HIPAA, you shouldn't be asking for this info
unless the patient has authorized you to receive it! This could
get you in trouble!"
D. "Why do you think Sue isn't talking about her worries?"
Correct Answers B
A med order reads: "Hydromorphone, 2 mg IV every 3-4 hours
PRN pain." The prefilled cartridge is available with a label
reading "Hydromorphone 2mg/1mL." The cartridge contains 1.2
mL of hydromorphone. Which nursing action is correct?
A. Give all medication in the cartridge bcause it expanded when
it was mixed.
B. Call the pharmacy and request the proper dose.
C. Refuse to give the med.
D. Dispose of 0.2 mL correctly before administering the drug.
Correct Answers D
,A medication order reads: "K-Dur, 20 mEq po b.i.d." When and
how does the nurse correctly give this drug?
A. Daily at bedtime by subcutaneous route
B. Every other day by mouth
C. Twice a day by the oral route
D. Once a week by transdermal patch Correct Answers C
The abbreviation "b.i.d." referes to twice-a-day administration.
po (by mouth) refers to administration by the oral route.
A nurse administers a dose for an oral medication fro
hypertension to a patient who immediately vomits after
swallowing the pill. What would be the appropriate initial action
of the nurse in this situation?
A. Readminister the medication and notify the PCP
B. Readminister the pill in a liquid form if possible
C. Assess the vomit, looking for the pill
D. Notify the PCP Correct Answers C
Assess the vomit for the pill and contact the PCP to see if
another pill should be administered.
A nurse assesses the stool of patients who are experiencing GI
problems. In which patients would diarrhea be a possible
finding? Select all that apply.
A. A patient who is taking narcotics for pain
B. A patient who is taking laxatives
,C. A patient who is taking diuretics
D. A patient who is dehydrated
E. A patient who is taking amoxicillin for an infection
F. A patient taking OTC antacids Correct Answers B, E, F
Diarrhea is a potential effect of treatment with amoxicillin
clavulanate, laxatives, or OTC antacids. Narcotics, diuretics, and
dehydration may lead to constipation.
A nurse caring for a patient's hemodialysis access documents the
following: "5/10/15 0930 Arteriovenous fistula patent in right
upper arm. Area is warm to the touch and edematous. Patient
denies pain and tenderness. Positive bruit and thrill noted."
Which documented finding would the nurse report to the PCP?
A. Positive bruit noted
B. Are is warm to touch and edematous
C. Patient denies pain and tenderness
D. Positive thrill noted Correct Answers B
The nurse would report that the site is warm and edematous as
this could be a sign of a site infection. The thrill and bruit are
normal findings caused by arterial blood flowing into the vein. If
these are not present, the access may be cutting off. No report of
pain is a normal finding.
A nurse caring for patients in a long-term care facility is often
required to collect urine specimens from patients for lab testing.
Which techniques for urine collection are performed correctly?
Select all that apply.
, A. The nurse catheterizes a patient to collect a sterile urine
sample for routine urinalysis.
B. The nurse collects a clean-catch urine specimen in the
morning from a patient and stores it at room temperature until an
afternoon pick-up.
C. The nurse collects a sterile urine specimen front he collection
receptacle of a patient's indwelling catheter.
D. The nurse collects about 3 mL of urine from a patient's
indwelling catheter to send for a urine culture.
E. The nurse collects a urine specimen from a patient with a
urinary diversion by catheterizing the stoma.
F. The nurse discards the first urine of the day when performing
a 24-hour urine specimen collection on a patient. Correct
Answers D, E, F
A urine culture requires about 3 mL of urine, whereas routine
urinalysis requires at least 10 mL of urine. The preferred method
of collecting a urine specimen from a urinary diversion is to
catheterize the stoma. For a 24-hour urine specimen, the nurse
should discard the first voiding, then collect all the urine voided
for the next 24 hours. A sterile urine specimen is not required
for a routine urinalysis. Urine chemistry is altered after urine
stands at room temperature for a long period of time. A
specimen from the collecting receptacle may not be fresh urine
and may result in an inaccurate analysis.
A nurse caring for patients in an extended-care facility performs
regular assessments of the patients' urinary functioning. Which
patients would the nurse screen for urinary retention? Select all
that apply.