Practice Test Assessment Performance

Practice Test Assessment Performance Correct The practical nurse (PN) performs a random blood glucose test for a client with a history of hypoglycemia and complains of dizziness. After test completion, which action should the PN perform first? Remove gloves and wash hands. Document results and actions in the medical record. Dispose of lancet and test strip in proper receptacle. Discuss the test results with the client. Rationale Disposal of the lancet and test strip (C) prevents the transmission of bloodborne pathogens and is the priority. (A, B, and D) should follow, implementing sharps precautions. Regarding client confidentiality, what information represents the correct understanding by the practical nurse of the guidelines set forth by HIPAA (Health Insurance Portability and Accountability Act)? Only clients can pick up their prescriptions at a pharmacy. Past medical records for clients should be stored in a secured place. Computers that access client information cannot be in the public part of a nursing station. Whiteboards with a list of client names are prohibited in areas that the public can see. Rationale The Health Insurance Portability and Accountability act of 1996 (HIPPA) establishes that records with protected health information (PHI) must be stored in a secured place. The other options are not part of the HIPPA act. Which action should the practical nurse (PN) implement to provide a sense of control to a toddler who is hospitalized? Put a cover over the child's crib. Ask parents to stay with the child. Assign the same nurses to care for the child. Follow the child's usual routines for feeding and bedtime. Rationale Routines are important to toddlers and give the child a sense of control, so following the child's usual routines during hospitalization should be implemented as much as possible. Which interventions should the practical nurse (PN) implement in the postoperative period for a client who had surgery for cancer of the oral cavity? (Select all that apply.) Select all that apply Provide meticulous oral hygiene. Advise the client to avoid straining at stool. Obtain daily weights to determine need for NGT feedings. Observe for temporary or permanent loss of taste. Monitor for gastric indigestion. Rationale Postoperative problems related to excision of a cancerous lesion in the oval cavity include the risk for infection, delayed wound healing in the oral mucosa, and gustatory deficits, if the client's tongue is resected or biopsied. Meticulous oral hygiene reduces oral flora and minimizes the risk for infection. Monitoring daily weight provides information about the client's need for supplemental NGT feedings to improve nutritional intake for healing and recovery. Observing for temporary or permanent loss of taste may indicate trauma of the tongue and glossopharyngeal nerve. Which intervention is most important for the practical nurse to implement when suctioning the nasopharyngeal airways for a child after cardiac surgery? Perform oropharyngeal suctioning PRN. Suction for no longer than 5 seconds at a time. Assess for symptoms of respiratory distress during suctioning. Administer supplemental oxygen before and after suctioning. Rationale Hypoxia increases the cardiac workload after cardiac surgery, so supplemental oxygen should be administered with a manual resuscitation bag before and after suctioning (D) to prevent hypoxia. Although (A, B, and C) should be implemented, providing oxygenation is most important. To maintain a patent airway, oropharyngeal suctioning for a child after cardiac surgery should be performed PRN without deep insertion of the suction catheter which can cause vagal stimulation and laryngospasm. Suctioning should be intermittent and maintained for no more than five seconds to prevent depleting the oxygen supply. Signs of respiratory distress warrant cessation of suctioning if the client is experiencing intolerance. A female client with terminal cancer is tearful and is becoming increasingly withdrawn from her family and the nursing staff. She refuses medications, treatments, food, and frequently says, "Why is God doing this to me?" Which intervention should the practical nurse implement? Monitor for an increased suicide risk. Implement measures to reduce her pain level. Contact her religious advisor to help her face death. Initiate discussions about her wishes for end-of-life care. Rationale The client's religious advisor should be contacted to assist the client cope with her spiritual distress regarding death (C). Although discussions about end-of-life care (D) should be initiated, the client's religious advisor, family, or healthcare provider should assist her in coordinating her wishes. The client's physical distress is influenced by (A and B) but do not address her expressed spiritual needs.