RNSG 2331 - Exam-1-capstone. (100% correct answers)

1. An angry client visits the primary healthcare provider’s office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client? You answered this question Incorrectly 1. All client appointment calls are transferred to the scheduling clerk. 2. The client will have to speak to the primary healthcare provider. 4. Medical records must stay within the facility unless requested by another primary healthcare provider. 3. Correct: The client has the right to the personal medical record. Generally, a period of time is required to get the record copied. The client may be charged for the copy. This assures the client that the request will receive attention. 1. Incorrect: This response dismisses the client's feelings and may only anger the client further. The response does not address the reason for the client's anger. The statement may be true; however, the client does have the right to request and receive a copy of the medical record. 2. Incorrect: The primary healthcare provider does not have to be contacted, as there should be policies in place to grant the request for a copy of the medical record. Also, telling the client to speak to the healthcare provider would not address the reason for the client's anger. This would dismiss the client's feelings. 4. Incorrect: The client has a right to the medical record. Records may also be requested by other providers with consent of the client. The client's feelings should be addressed and the client should be informed that the medical record will be provided as requested. Question: A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include? You answered this question Incorrectly 3. Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well. 1., 2., 4. & 5. Correct: If a person reveals that suicide is being considered, this should never be kept secret. Help should be sought for the person immediately. It is also important to be direct and non-secretive with suicidal clients. It is appropriate to express concern for their thoughts. The use of empathy, warmth and concern indicates to the client that their feelings are being understood and viewed as real, which helps to build trust with the client. Resources for assistance are important to include in all health teaching programs. The teens need to know what resources are readily available if someone is considering suicide. The client contemplating suicide should not be left alone. This is for the client's safety until further assistance can be obtained 3. Incorrect: Most clients who commit suicide have told at least one person that they were contemplating suicide before thy actually committed the act. Therefore, suicidal comments should be considered important risk factors that require evaluation, and all comments should be taken seriously. Anyone expressing suicidal feelings needs immediate attention. Question: The nurse should question which prescription for a client diagnosed with acute heart failure? You answered this question Correctly 1. 2 gram of sodium (Na) diet. 2. Digoxin 0.25 mg IV q 4 hours times 3 doses. 3. Furosemide 40 mg IVP stat. 4. Correct: The client is in fluid overload and does not need the normal saline (NS) at 125 mL/hr. NS is an isotonic solution. It goes in the vascular space and stays there without shifting out to the cells. This could cause additional overload in the vascular space as well as cause the BP to increase. The other prescriptions are acceptable. 1. Incorrect: This is an appropriate measure Na restricted diet will help to lower the serum Na and decrease H2O retention. This does not need questioning. 2. Incorrect: Digoxin is a digitalis glycoside. It slows conduction and strengthens the force of contraction of the heart. Therefore, this medication that increases cardiac contractility and reduces the heart rate does not need questioning. 3. Incorrect: Furosemide is a diuretic. It enhances renal excretion of Na and H2O and reduces systemic and pulmonary congestion. This medication prescription does not need questioning. Question: The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified? You answered this question Incorrectly 1. Blood pressure 102/68 2. Glucose 118 3. UOP 440 mL over previous 8 hour shift. 4. Correct: This is a beta blocker. It slows the heart rate. If a client’s heart rate is less than 60 beats per minute, notify the primary healthcare provider and ask if the client should receive this medication. Administering a beta blocker to a client who has a heart rate less than 60 could possibly cause the client to develop symptomatic bradycardia and hypotension. 1. Incorrect: If the client’s BP drops below 90/60, this beta blocker should be held and the primary healthcare provider notified. The BP in this option is high enough to administer the medication, but the BP in clients on beta blockers should be monitored and the client should be taught about signs and symptoms of hypotension. 2. Incorrect: This is a normal glucose level. If the client is a diabetic, beta blockers can mask the signs of hypoglycemia. There diabetics on beta blockers should monitor their blood sugar carefully. 3. Incorrect: Urinary output is adequate. Beta blockers do not alter renal function. However, if pulse and BP are reduced too much, renal perfusion could ultimately be affected. Question: Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months? You answered this question Correctly 1. Weight loss 4. Decreased facial hair 2. , 3. & 5. Correct: Decreased wound healing is a side effect with prolonged steroid use due to the immunosuppressive effects. All steroid medications, such as prednisone, can lead to sodium retention which then leads to dose related fluid retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid appearance (moon face) is a side effect that is created from the abnormal redistribution of fat from prolonged steroid use. 1. Incorrect: Within one month after corticosteroid administration, weight gain is seen rather than weight loss. 4. Incorrect: Facial and body hair increase with prolonged steroid use. This excessive growth of body hair, known as hirsutism, is one of the numerous potential side effects of prednisone. Question: Which interventions should be included in the plan of care for an adult client with constipation? You answered this question Correctly 5. Encourage the client to delay the urge to defecate until after a meal. 1., 2., 3. & 4. Correct: Clients should have ample time for defecation. Rushing the client may lead to a client ignoring the urge. Since clients may be hesitant to have a bowel movement in the presence of others, privacy should be provided. (The nurse may need to stay with weak or disabled clients.) Increasing fluid intake will lead to softer stools. This makes defecation easier. Fiber deficiencies may contribute to constipation. Fiber in the diet adds bulk to the stools which help them pass more readily through the intestines. 5. Incorrect: Ignoring the urge to defecate may increase the risk of constipation. Trying to defecate after a meal when peristalsis is increased may be helpful; however, if the urge occurs at other times, the client should go to the bathroom at that time to prevent constipation. Question: A client asked the nurse what could have caused them to develop right sided heart failure? What would be the best response by the nurse? You answered this question Correctly 2. Long term hypertension. 3. The inability of the mitral valve to close properly. 4. Narrowing of the aorta. 1. Correct: Yes, the right side of the heart pumps to the lungs. When the client has higher pressure in the pulmonary circuit from such things as emphysema, the pulmonary pressure can exceed the systemic pressure. The result is back flow to the right side of the heart and resulting right sided heart failure. 2. Incorrect: No, that’s left-sided heart failure. Hypertension increases afterload which can ultimately result in back flow to the left side of the heart and resulting left sided heart failure. 3. Incorrect: Not related to pulmonary hypertension. The mitral valve is located between the left atrium and left ventricle. If mild, there may be little or no obvious symptoms. However, if severe, left sided heart failure may occur. 4. Incorrect: Not related to pulmonary hypertension. Narrowing of the aorta makes it harder to get blood out of the left ventricle (high afterload). The resulting back flow of blood would result in left sided heart failure. Question: A client diagnosed with glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription? You answered this question Correctly 2. Prevents injury 3. Promotes rest 4. Stimulates RBC production 1. Correct: Bedrest and the supine position promote diuresis. When the client is supine, there is a gradual shift of fluids away from the legs toward the thorax, abdomen and head. This increased volume causes the right atrium of the heart to stretch and release ANP, which leads to diuresis: renal blood flow increases due to vasodilation, and aldosterone and ADH secretion are inhibited. 2. Incorrect: Bedrest can keep the client from falling and injuring self; however, that is not why it has been prescribed. 3. Incorrect: Promotion of rest is good, but this is not why the primary healthcare provider prescribed it. Simply promoting does not help improve the symptoms listed. The reason the client needs bedrest should focus on relieving the symptoms listed in the stem. 4. Incorrect: No relationship between bedrest and red blood cell production exists. Question: The nurse wants to provide anticipatory guidance for a group of young parents who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these parents? You answered this question Incorrectly 1. Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training. 5. Assist your child with all tasks to promote independence. 2. , 3. & 4. Correct: Letting the child do things on their own will promote a sense of self control and independence during this stage of autonomy versus shame and doubt. Finger foods allow for independence with eating and builds a sense of autonomy. At this age, the child becomes increasingly aware of separateness from the parent. The need is for the parent to be available for emotional support when needed. However, if emotional needs are inconsistently met or if the parent rewards clinging, dependent behaviors and withholds nurturing when the child demonstrates independence, feelings of rage and fear of abandonment may develop in adulthood. The support provided by the parent can lessen feelings of anxiety for the child when the emotional presence is needed. 1. Incorrect: Strict toilet training can result in retention of feces and constipation. In addition, strict toilet training practices before the child is ready can result in frustration and shame. 5. Incorrect: Assisting with all tasks will promote dependence. This does not give the child opportunities to perform age-appropriate tasks independently and gain a sense of autonomy. Notice the word "all"? This conveys a thought or concept that has no exceptions. Words such as just, always, never, all, every, none, and only are absolute and place limits on the statement that generally is considered correct. Statements including these words generally make the statement false as the statement is general and broad and does not allow for exceptions. Question: The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse? You answered this question Incorrectly 1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma, and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. Correct: The information does not let you know if any of the nurses have had chickenpox or not. If a nurse has not had chickenpox, then they should not care for the client with shingles. The varicella zoster virus is responsible for chickenpox and shingles. The virus is lying dormant in the nerve ganglia and under certain conditions erupts (for example: stress). With the information you have, it would be best not to assign the new admit to the nurse who is pregnant. The other set of nurses and clients have no identified contraindications to taking care of the client with shingles. 1. Incorrect: This is an appropriate assignment. There are no identified contraindications for the nurse or clients to prevent the nurse from caring for a client with shingles. 2. Incorrect: This is an appropriate assignment. There are no identified contraindications for the nurse or clients to prevent the nurse from caring for a client with shingles. 3. Incorrect: This is an appropriate assignment. There are no identified contraindications for the nurse or clients to prevent the nurse from caring for a client with shingles. Question: A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic? You answered this question Correctly 1. A shower will make you feel better. 3. Have you thought about taking a shower? 4. I need you to take a shower. 2. Correct: Schizophrenia is a thought disorder. Many clients with schizophrenia are concrete thinkers and have difficulty making decisions. The nurse needs to be direct, clear and concise in communicating with the client. This is a direct, clear and concise statement that guides the client to perform the needed activity. 1. Incorrect: Many clients with schizophrenia are concrete thinkers. The nurse needs to be direct, clear and concise in communicating with the client. The client may not comprehend how the shower improves the overall sense of well-being and would remain reluctant to take the shower. 3. Incorrect: Clients diagnosed with schizophrenia often have trouble making decisions. The client needs to be guided with simple, direct instructions. 4. Incorrect: This focuses on the nurse’s need, not the client’s need. Do not select answers that focus on the nurse. This does not improve the client's decision making ability nor does it provide guidance to the client for meeting the hygiene needs. Question: A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction? You answered this question Correctly 1. Relieve nausea 3. Control fluid and electrolyte imbalance 4. Remove the precipitating irritants 2. Correct: In clients with pancreatitis, the pancreatic enzymes cannot exit the pancreas. These enzymes, when activated, begin to digest the pancreas itself. The enzymes become activated in the pancreas when fluid or food accumulates in the stomach. The goal in treating this client is to stop the activation of the pancreatic enzymes. Treatment is focused on keeping the stomach empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion (pancreas digesting itself) is painful for the client and can lead to other problems such as bleeding. 1. Incorrect: The primary purpose of the NG tube to suction is to keep the stomach empty and dry to decrease pancreatic enzyme production, not to relieve nausea. 3. Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid and electrolyte disturbances rather than helping to control them. 4. Incorrect: Although the food in the stomach causes the pancreatic enzymes to become activated in the pancreas due to the obstruction, the food is not considered an irritant. Precipitating irritants are not a part of the pathophysiology occurring with pancreatitis. Question: An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care? You answered this question Correctly 2. Supine position for 6 hours 4. Irrigate NG tube every 2 hours 5. Raise four siderails 1. , & 3. Correct: Vital signs post procedure are important to monitor for any post- procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns. 2. Incorrect: Supine position for 6 hours is contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart catheterization. 4. Incorrect: A client who is going for a gastroscopy procedure cannot have a nasal gastric tube. An NG tube would interfere with the procedure. 5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have call light within reach. Question: A client’s last two central venous pressure (CVP) readings were 13 cm of water. The nurse would expect the client to manifest which associated signs and symptoms? You answered this question Incorrectly 1. Dry oral mucus membranes 3. Orthostatic hypotension 2. , 4., 5. & 6. Correct: The normal range for CVP is 2-8 cmH2O or 2-6 mmHg. Therefore, the readings of 13 cmH2O are high and may be the result of fluid volume excess. The signs and symptoms of FVE include: tachynea, rales, and jugular vein distention from the increased volume and preload. Acute weight gain is one of the best indicators of FVE due to circulatory overload. 1. Incorrect: The CVP is high and correlates with fluid volume excess. Dry oral mucous membranes indicate fluid volume deficit. 3. Incorrect: The CVP is high and correlates with fluid volume excess. Orthostatic hypertension indicates fluid volume deficit. Question: A client with a history of command hallucinations was admitted to the hospital yesterday. What questions are most important for the nurse to ask? You answered this question Correctly 3. "How are you feeling today?" 4. "Did you have difficulty sleeping last night?" 1., 2. & 5. Correct: The nurse must assess for hallucinations. The nurse needs to know what the voices are saying to determine the level of threat. The nurse needs to know if the command hallucination exists and whether it involves harming self or others which must be reported. These answers are important to know, as the client has a history of command hallucinations. 3. Incorrect: The priority is safety of the client and others on the unit. This question does not get the most essential information related to command hallucinations that may cause the client to engage in behavior that is harmful to self or others. 4. Incorrect: This question does not focus on the problem: command hallucinations. If you assume the worse, you want to know if the voices from the command hallucinations are telling the client to harm self or others. Question: The nurse is caring for a client diagnosed with herpes varicella zoster. What pharmacologic agent should the nurse anticipate the primary healthcare provider will prescribe? You answered this question Incorrectly 1. Metronidazole 3. Ceftriaxone 4. Ampicillin 2. Correct: Herpes varicella zoster is a virus that causes chickenpox in children and shingles in adults. An antiviral such as acyclovir, is indicated. 1. Incorrect: Herpes varicella zoster is a virus; an antiviral is indicated, not a nitromodazole antimicrobial, such as metronidazole. Metronidazole may have additional classifications such as: amebecide, antibiotic, antibacterial, etc. 3. Incorrect: Herpes varicella zoster is a virus; an antiviral is indicated, not an antibiotic such as ceftriaxone. 4. Incorrect: Herpes varicella zoster is a virus; an antiviral is indicated, not an antibiotic such as ampicillin. Question: Which client will the charge nurse intervene on behalf when making rounds? You answered this question Correctly 1. The client turned to left side 1 ½ hour ago. 3. Client who is day one postop from hip replacement with abduction pillow in place. 4. The client who is in buck’s traction with foot boots. 2. Correct: Limit sitting in a chair to less than 2 hours. Prolonged sitting or lying in one position predisposes the client to skin breakdown and other hazards of immobility. 1. Incorrect: Clients should be turned at least every 2 hours, so this client is within the acceptable time frame for being turned. 3. Incorrect: The client with hip replacement needs the abduction pillow. This prevents dislocation of the hip prosthesis by helping to maintain the femoral head component in correct position. 4. Incorrect: The client in buck’s traction needs foot boots to avoid foot drop. Therefore, this is an appropriate intervention. Question: The nurse is preparing a client for a renal biopsy. Which is most important for the nurse to assess prior to this procedure? You answered this question Correctly 1. BUN and creatinine 2. NPO status and signature on consent 4. Serum potassium and urine sodium 3. Correct: Yes. Before you insert a needle into an organ for a biopsy, it would be best to know the client's bleeding time because there is a risk of bleeding when the biopsy is performed. 1. Incorrect: Although these are related to renal function, they do not impact the procedure itself. Therefore, they are not essential for the procedure. 2. Incorrect: Although both of these are carried out, they are not the priority over risk of bleeding. Always think what could be life threatening. 4. Incorrect: Although both serum potassium and urine sodium are related to renal function, they do not impact the procedure itself. Therefore, they are not essential for the procedure. Question: What assignment would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? You answered this question Correctly 1. Teaching the client perineal care. 2. Changing a colostomy bag on a client. 4. Taking the initial vital signs on a client who is to receive blood. 3. Correct: The most appropriate task for a non-licensed person would be serving the diet tray for a client. This does not require experience for a particular skill nor does it require higher level skills that would require a licensed person to perform. 1. Incorrect: Teaching is the responsibility of the RN and cannot be delegated to a LPN nor a non-licensed personnel. 2. Incorrect: Changing the colostomy bag on a client will need someone with the experience/skill of performing this task. Although some agencies allow UAP's to change colostomy bags, there may be further assessment needed associated with the ostomy, such as skin condition around the ostomy. This would not be the best option to assign to the UAP. 4. Incorrect: UAPs can take VS, but they must be very cautious in order to note changes and the client receiving blood should be assessed for any s/s of reaction. Therefore, it would be best for the licensed personnel to obtain the initial v/s prior to blood administration to assess the client's status and have a baseline for evaluating the client's response to the blood administration. Question: A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment? You answered this question Incorrectly 3. Decreased body temperature 4. Constipation 1., 2. & 5. Correct: Serotonin syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal. 3. Incorrect: Increased body temperature is expected as is increased diaphoresis. 4. Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome. Question: A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? You answered this question Correctly 3. Walker 1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. The risk of respiratory compromise increases as the neurologic status deteriorates. A hospital bed is needed so that the head of the client’s bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The client with hepatic encephalopathy is unresponsive due to accumulation of toxins and may need suctioning if unable to clear secretions from the oropharynx. Hepatic encephalopathy frequently has associated bleeding varices. The increasing ascites leads to hypovolemia. Both of these conditions can result in hypoxemia for the client at the end stages of liver disease; therefore, oxygen therapy is provided. 3. Incorrect: As hepatic encephalopathy progresses and toxins accumulate, the client lapses into a coma. Therefore, the unresponsive client will not be ambulatory and would not need a walker. Question: The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat through a non-tunneled central venous catheter lumen with no other medication or fluid infusing. In what order should the nurse administer this prescription? You answered this question Incorrectly The Correct Order Your Selected Order Proper administration of medication through a non-tunneled central venous catheter: First, cleanse the access port. Failure to cleanse the port first would increase the risk of infection from contamination when the port is accessed. Second, connect 10 mL normal saline to access port. This 10 mL syringe will be connected to first check patency and then for flushing prior to medication administration. At least 10 mL of normal saline is used to flush central lines. Third, gently aspirate for blood. Fourth, flush saline using push-pause method. This method is utilized to help clear the catheter of blood or drugs that could potentially adhere to the internal surface of the central line catheter. This creation of turbulent flow from pausing then pushing causes swirling of the fluid and theoretically removes blood and medications from the walls of the catheter, which reduces the risk of occlusion in the catheter. Fifth, administer phenytoin. Sixth, flush with normal saline, then with heparin. Standard flushing solutions used most frequently for central venous access devices include normal saline and/or heparinized sodium chloride. Low dose heparin flushes are generally used to fill the lumen of the central line between use in order to prevent thrombus formation and maintain patency of the catheter for a longer period of time. Question: The school nurse has identified a large outbreak of viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include? You answered this question Correctly 1. Use personal handkerchief to wipe the eye of discharge. 2. , 3., 4. & 5. Correct: All of these measures will promote comfort and decrease risk of transmitting infection. Clients should also avoid touching the eyes and shaking hands/touching other. Cool compresses provide symptomatic relief. 1. Incorrect: Use a new tissue every time you wipe the discharge from the eye. You can dampen the tissue with clean water to clean the outside of the eye. If a personal handkerchief is used, reinfection can occur. Question: Which statements should a nurse make when educating a client about advance directives? You answered this question Correctly 1. Used as guidelines for client treatment should the client's family deem them necessary. 5. Allows the client's spouse to make end-of-life decisions. 2. , 3. & 4. Correct: Advance directives are legally binding documents. Documentation is required in the medical record as to whether an advance directive exists. If one exists, a copy should be placed in the medical record. The document is prepared by the client detailing wishes for treatment should the client become unable to make informed healthcare decisions. 1. Incorrect: The family’s wishes for treatment of the client do not take the place of or negate the client’s advance directive. 5. Incorrect: The spouse's wishes for treatment of the client do not take the place of or negate the client's advance directive. Question: A group of women ask a community health nurse how to prevent stress incontinence. What points should the nurse teach these women? You answered this question Correctly 1. Limit alkaline foods. 4. Eat less fiber. 5. Perform high-impact exercise. 2. , & 3. Correct: Fluids containing caffeine, carbonation, alcohol or artificial sweeteners act as irritants to the bladder wall and should be avoided. Acidic foods, such as citrus fruits, are also irritants. Obesity can cause increased pressure on the bladder, leading to incontinence. 1. Incorrect: Acidic foods, not alkaline, are bladder irritants and should be avoided. 4. Incorrect: The client should eat more fiber (not less) to prevent constipation, which can put pressure on the bladder and be a cause of urinary incontinence. 5. Incorrect: High-impact exercise puts pressure on the pelvic floor muscles and can increase leakage. Try Pilates, a gentle method of stretching and strengthening core muscles, which has become a more popular treatment for stress incontinence. Which client admitted to the emergency department should the nurse assess first following shift report on assigned clients? You answered this question Correctly 1. Client reporting inability to void and a distended bladder on palpation. 2. Client diagnosed with a confirmed closed fracture of the tibia. 3. Client who has a suspected corneal laceration. 4. Correct. A rigid abdomen may indicate bleeding or other causes of peritonitis which takes priority over the other three, more stable clients. This could lead to shock in this client. Conditions requiring immediate treatment include cardiac arrest, anaphylaxis, multiple trauma, shock, poisoning, active labor, drug overdose, severe head trauma, and severe respiratory distress. 1. Incorrect. Although this condition may be uncomfortable and could lead to renal problems if not resolved, it does not take priority over a client who is bleeding. 2. Incorrect. This person is likely experiencing pain, but this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing into the peritoneum. Remember, pain never killed anyone. 3. Incorrect. This client with a corneal laceration would be experiencing pain and needs attention to avoid vision loss. However, this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing in the peritoneum. Remember, ascites is fluid in the peritoneal cavity. Question: A client comes into the emergency department (ED) and demands to be seen immediately, but refuses to tell the triage nurse the problem. During the assessment, the client starts yelling and shaking their fist. For the nurse's safety, what should be the nurse’s initial action? You answered this question Incorrectly 1. Tell the client to stay calm, and that treatment will be provided soon. 2. Explain that unless the client behaves, they will be sent away from the ED. 3. Notify the client that security will be called if they do not go to the waiting room immediately. 4. Correct: Self-protection is a priority. There is no advantage to protecting others if medical caregivers are injured. Security officers and police must gain control of the situation first, and then care is provided. 1. Incorrect: This does not provide safety for the nurse and might increase the client's anger. 2. Incorrect: This is not a true statement and does not provide immediate safety for the nurse. Clients seeking treatment are not refused care in the ED. 3. Incorrect: This is not the initial action. Finding a safe place is the first action for the nurse's safety. Also, the angry client does not need to be sent to the waiting room around other clients at this time. Question: A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate? You answered this question Correctly 5. Provide three meals per day 6. Dangle legs 1., 2., 3., & 4. Correct: The symptoms presented are indicative of liver disease. Measuring abdominal girth will monitor for accumulating ascitic fluid. Clients with liver disease have fluid volume problems, so daily weight and I&O are indicated. This client is at risk for injury related to chronic fatigue and weakness, so fall prevention is indicated. The client may need help eating if fatigue is severe. 5. Incorrect: Poor tolerance to larger meals may be due to abdominal distension and ascites. Clients should eat smaller, more frequent meals (6/day). The recommended diet is high calorie and low sodium with protein regulated based on liver function. Between meal snacks should be provided. 6. Incorrect: Elevating legs enhances venous return and reduces edema in extremities. Dangling the leg would cause the fluid in the lower extremities to accumulate more. Question: The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN? You answered this question Incorrectly 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic needing assistance with bowel training. 1., 2., 3. Correct: These clients should be assigned to the RN as they will require more frequent assessment due to the nature of each diagnosis and have a potential for more rapid change in condition. Also, these clients may require skills by the RN that the LPN/VN could not do; for example, giving IV medications that asthma clients take; teaching the family about seizures, meds, and management; and administering TPN intravenously. 4. Incorrect: There is nothing in this option to indicate that the child is unstable. This assignment is appropriate for LPN/VN 5. Incorrect: This assignment is appropriate as the LPN/VN can provide care related to elimination needs. Question: A nurse is caring for a client who delivered a baby vaginally two hours ago. What signs and symptoms of postpartum hemorrhage should the nurse report to the primary healthcare provider? You answered this question Incorrectly 1. Two blood clots the size of a dime. 5. Firm fundus 2. , 3., & 4. Correct: Lochia should not exceed an amount that is needed to partially saturate four to eight peripads daily, which is considered a moderate amount. Perineal pad saturation in 15 minutes or less is considered excessive and is reason for immediate concern. Saturation of a peripad in one hour is considered heavy. Also, trickling of bright red blood from the vagina can indicate hemorrhage and is often a result of cervical or vaginal lacerations. Bright red blood indicates active bleeding. Oliguria is a sign of fluid volume deficit. As blood volume goes down, renal perfusion decreases and urinary output (UOP) decreases. The kidneys are also attempting to hold on to what little fluid volume is left. 1. Incorrect: A few small clots would be considered normal and occur due to pooling of the blood in the vagina. Passage of numerous or large blood clots (larger than a quarter) would indicate a problem. 5. Incorrect: We worry about a boggy uterus. Uterine atony is a major cause of postpartal hemorrhage. The fundus feels firm as the uterus and uterine muscles contract to reduce the blood loss. Question: A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse’s assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation? You answered this question Incorrectly 1. Are you having trouble sleeping at night? 3. Are you having any sexual dysfunction? 4. Is your mood improving? 2. Correct: Myoclonus, high body temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal. 1. Incorrect: Sleep disturbances are common with depression. Selective serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed for assessment of this client. You should be concerned with the more serious or life-threatening issue. 3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is exhibiting significant symptoms of an adverse reaction which would take priority. 4. Incorrect: The response to the SSRI medications is important; however, there is a more significant issue in this case. The possible serotonin syndrome is a serious situation that would be the priority for the nurse to address. Question: Which clients would be appropriate for the RN to assign to an LPN/LVN? You answered this question Correctly 1. Seventy four year old client with unstable angina who needs teaching for a scheduled cardiac catheterization. 2. Sixty year old client experiencing chest pain scheduled for a graded exercise test. 5. Newly admitted ninety year old client with decreased urinary output, altered level of consciousness, and temperature of 100.8°F (38.2°C) 3. , 4., 6. Correct: The client who is five days post CVA is one of the most stable clients and could be assigned to the LPN/LVN. There is nothing in the option to indicate that this client is unstable. There is no indication that the eighty-four year old client with heart disease and dementia is unstable so this client can be assigned to the LPN/LVN. The client with chronic emphysema will experience shortness of breath. There is nothing to indicate that this client is unstable. 1. Incorrect: This client is unstable and should be cared for by the RN. Additionally, the RN is responsible for teaching. 2. Incorrect: This client is experiencing chest pain and is thus considered unstable and should be cared for by the RN. 5. Incorrect: This client has s/s that could indicate sepsis, so is considered unstable and should not be assigned to the LPN/LVN. Question: Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations? You answered this question Correctly 3. Herpes zoster. 4. Meningococcal 1., 2., & 5. Correct: By the age of two, the DTaP, IPV, MMR, Hib, varicella, pneumococcal, and rotovirus vaccines should have been received. The nurse should clarify this with the parent. 3. Incorrect: This vaccine is recommended for people 60 years or older whether or not the person has ever had chicken pox and is at risk for developing shingles. Although the vaccine can be given to adults between the ages of 50-59, routine administration is not recommended. 4. Incorrect: The minimum age for administering the meningococcal vaccine is two years of age. The recommended age for administering the meningococcal vaccine is at 11 or 12 years of age, or 13 through 18 years of age if they did not previously receive this vaccine. It is especially important for teens going to college and who are likely to stay in close quarters such as a dorm. Question: A client diagnosed with major depression is admitted to the psychiatric unit for electroconvulsive therapy (ECT). The client asks the nurse, "How many of these treatments do you think I will need?" What is the nurse's best response? You answered this question Correctly 1. That is a question you need to discuss with your primary healthcare provider. 3. You will need to take a treatment every month for at least a year. 4. Let's just take one treatment at a time, shall we? 2. Correct: Most clients require an average of 6 to 12 treatments, but some may require up to 20 treatments. These treatments are generally given two to three times per week for three to four weeks. The number of treatments required depends on the severity of the symptoms and how quickly the client improves. 1. Incorrect: The nurse should be able to answer this question based upon the generally accepted regimen for electroconvulsive therapy (ECT). 3. Incorrect: Treatments are usually administered every other day (three times per week). Since the average number of treatments is 6-12, it only takes a couple of weeks to a month, on average for the regimen. Treatments are performed on an inpatient basis for those who require close observation and care, but can be done on an outpatient basis for some clients. 4. Incorrect: This is poor therapeutic communication. The nurse did not answer the question and is belittling. The client has a right to be able to make informed decisions regarding care being provided. Question: The charge nurse is observing the work of an unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene? You answered this question Correctly 1. Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2. Closing the door when exiting the room of a client diagnosed with tuberculosis (TB). 4. Cleaning a blood pressure cuff with a disinfectant. 3. Correct: Gloves should be removed and hands washed before leaving each client’s room. Gloves quickly become contaminated and then become a potential vehicle for the transfer of organisms between clients. 1. Incorrect: No intervention is needed because this is an appropriate action. Do not carry soiled linen down the hall to place in a receptacle. 2. Incorrect: No intervention is required because this is an appropriate action. Clients with tuberculosis (TB) need to be on airborne precautions in a negative pressure room with the door closed. 4. Incorrect: Equipment used against intact skin should be thoroughly cleaned with low level disinfectant between uses to reduce the load of microorganisms to a level that is not threatening to the next client. Therefore, no intervention is needed since the action is appropriate. Question: Which statement made by a client post-thyroidectomy would require further investigation by the nurse? You answered this question Correctly 2. “It hurts when I move my head.” 3. “I feel pressure in my arm when you take my blood pressure.” 4. “My legs are weak.” 1. Correct. After this procedure the nurse should worry about the possibility of some of the parathyroids being accidentally removed with resulting hypoparathyroidism. Hypoparathyroidism results in hypocalcemia. Signs and symptoms include tingling, burning, or numbness of lips, fingers, and toes. The muscles may become tight and rigid, and seizures can result. 2. Incorrect. Pain is expected here. The incision is at the base of the neck, so movement of the head would increase the pain. 3. Incorrect. The sensation of pressure in the arm is considered normal when the BP is being measured. You worry if you see carpal spasm (+ Trousseau’s) which is indicative of neuromuscular excitability caused by hypocalcemia secondary to the inadvertent removal of some of the parathyroids. 4. Incorrect. Weak/flaccid extremities would be seen with hyperparathyroidism. In this case, we are concerned that the parathyroids may have been removed, resulting in hypoparathyroidism. The weakness in the legs is apparently from a different cause. However, the signs of possible hypoparathyroidism would be the priority to investigate. Question: A client, who only speaks Spanish, is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? You answered this question Correctly 2. Draw pictures of what the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery. 1. Correct: Audiotapes made in the language of high volume clients who speak a language other than English is helpful to inform clients about admission procedures, room and unit orientation, and pre-surgical procedures. The tapes are received from sources where reliability of information is provided. This is the most reliable option for providing accurate information. 2. Incorrect: This is not the best option. Some pre-surgical procedure may be difficult to draw or difficult for the client to understand what was drawn. There is no way to know if the client is understanding what the nurse is trying to communicate through the pictures. Client safety could be compromised if decisions are made based on inaccurate perceptions. 3. Incorrect: This is called “Getting by” and may have to be used when the nurse cannot speak the client’s language, and there are no interpreters, audiotapes, or written materials available to inform the client in their language. This is not the best option and should be used only if other more reliable means for interpreting are not available. 4. Incorrect: Disadvantages of using ad hoc interpreters include compromising the client’s right to privacy and relying on someone without training as an interpreter. Due to lack of training or experience, ad hoc interpreters may leave out important words, add words, or substitute terms that make communication inaccurate. This may have to be done at times if tapes or other reliable means of interpreting are not available. However, this is not the best option. Question: The nurse is advising the family of a client receiving palliative care on alternative methods for pain control to be used in conjunction with pain medications. Which method should the nurse include? You answered this question Correctly 2. Administering pain medication when pain is rated at 5 out of 10 4. Exercise 1. , 3., & 5. Correct: These are types of alternative pain control that could be used in conjunction with traditional pain management. They can be used to provide relaxation and comfort; mind-body therapies such as meditation, guided imagery and hypnosis may be effective. Other measures may include: acupuncture, therapeutic touch, music therapy and spiritual practices such as prayer. These have been found to be effective in helping to reduce pain. 2. Incorrect: Pain medication is traditional, not alternative pain control. Also, pain medication should be provided prior to a rate of 5/10. 4. Incorrect: The client is likely not going to be able to exercise. Movement during pain may increase pain. Question: When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure, but received his preoperative medication approximately 10 minutes ago. What would be the appropriate action by the nurse? You answered this question Correctly 1. Have the client sign the permit, as he verbalizes understanding. 2. Witness the form after having the client sign it. 3. Have his wife sign the form as she witnessed his statement that he understands. 4. Correct: The client must sign the operative permit or any other legal document prior to taking preoperative drugs that can affect judgment and decision-making capacity. 1. Incorrect: The client’s verbal understanding does not override the fact that he has received medication that can alter thought processes and decision-making. 2. Incorrect: Witnessing would not make this document legal. The consent would not be valid because the client has already received the pain medication that could alter the thought process. 3. Incorrect: When a client is of legal age (unless an emancipated minor) and of sound mind, it would be inappropriate for the spouse to sign the form for surgery. In order to be valid it must be the client who signs it, unless there is a legal power of attorney, durable power of attorney, or healthcare surrogate. Question: The nurse evaluates the effectiveness of discharge teaching for a client with type I diabetes mellitus. Which statement by the client would indicate to the nurse that teaching has been effective? You answered this question Correctly 2. "I will need to decrease my insulin dose when I develop an infection." 3. "I need to lose weight since obesity decreases insulin resistance." 4. "Increased stress levels will cause the glucose level in my blood to go down." 1. Correct: Regular exercise decreases the need for insulin. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduce hepatic production of glucose. 2. Incorrect: When an infection occurs, blood sugar increases. The normal response to infection is to increase available glucose to assist in combating the infection. This will increase the requirement for insulin, not decrease it. 3. Incorrect: Obesity increases not decreases insulin resistance, so the cells do not respond normally (are resistant) to insulin. Maintaining a healthy weight with exercise and diet can result in less need for insulin (less resistance to insulin) and less problems in individuals with type 2 diabetes. 4. Incorrect: Emotional upset and undue stress results in increased circulating catecholamines. This will increase the blood glucose levels and increase the requirement for insulin. Question: What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung? You answered this question Incorrectly 5. Maintain closed drainage unit at the level of the client's chest. 1., 2., 3., & 4. Correct: A pleural effusion is a collection of fluid in the pleural space that moves to the bottom of the chest cavity when upright. The semi-Fowler's position allows the client to be in an upright position to promote drainage and facilitate ease of respirations by promoting lung expansion. Since lung expansion is compromised with a pleural effusion, the oxygen level should be assessed using an oxygen saturation monitor. The client's respiratory status should be assessed at least every 2 hours: respiratory rate, work of breathing, breath sounds, pulse oximetry. The development of kinks, loops, or pressure on the drainage tubing can produce back pressure, which may force fluid back into the pleural space or interfere with the drainage. 5. Incorrect: The closed drainage unit should be placed below the level of the client's chest to prevent drainage from flowing backward into the pleural space. Question: During the insertion of a urinary catheter, the tip of the catheter touches the client’s thigh. What action should the nurse take? You answered this question Correctly 1. Wipe the tip of the catheter with alcohol. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit. 2. Correct: Indwelling catheter insertion is a sterile procedure. If contamination occurs, do not turn back on sterile field. Get on the call light to request another urinary catheter and sterile gloves to continue the procedure. Continuing the procedure with contaminated equipment would jeopardize the client's safety. 1. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. The client would be at high risk of developing a urinary tract infection. The catheter cannot be made sterile by the use of alcohol. 3. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. Inserting the now non-sterile catheter puts the client at risk for infection. There is no reason at this time to start antibiotics. 4. Incorrect: The catheter is contaminated, but the sterile field is still okay. It is more cost efficient to have someone bring the nurse another catheter and pair of sterile gloves rather than getting an entire sterile kit. Question: A client with cancer of the larynx undergoes radiation therapy for 5 weeks prior to a neck dissection and tumor excision. The client asks the nurse how long the post surgical recovery time will be. How should the nurse reply? You answered this question Correctly 1. "I really don't know. It is different for everyone, but speak to your surgeon." 2. "Your medical insurance will cover the whole length of your stay, so don't worry." 3. "You shouldn't worry about how long you are going to stay. You should focus on getting better." 4. Correct: This is the best, most accurate response. Radiation can cause tissue trauma and changes that can delay wound healing. 1. Incorrect: On NCLEX®, the nurse should know not to put work off on someone else. This answer avoids responsibility and does not provide the client with the information requested. 2. Incorrect: This answer assumes the client has financial concerns, but this is not the question the client asked. It also dismisses the client by being told not to worry. 3. Incorrect: This answer brushes off the client. Never pick an answer that brushes off the client’s concern. Question: What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby’s lungs? You answered this question Correctly 1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Correct: Betamethasone is used to stimulate maturation of the baby’s lungs in case preterm birth occurs. This medication is given to help prevent respiratory distress syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the alveoli from collapsing. 1. Incorrect: Magnesium sulfate is given to stop preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby’s lungs. 2. Incorrect: Terbutaline is contraindicated in preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby’s lungs. 3. Incorrect: Methotrexate is used to stop the growth of the embryo in ectopic pregnancy so that the fallopian tube can be saved. It is not an agent used in the management of preterm labor. Question: The nurse is caring for a client who has just arrived at the emergency department with suspected acute myocardial infarction. Which medications should the nurse administer immediately? You answered this question Correctly 2. Heparin 5. Furosemide 1. , 3., & 4. Correct: Initial management should take place immediately. According to the American Heart Association/Heart & Stroke Foundation of Canada and the American College of Cardiology, oxygen, SL nitroglycerin, morphine, and aspirin should be administered immediately. The initial goal of therapy for clients with an acute MI is to restore perfusion to the myocardium as soon as possible. Oxygen is appropriate and advisable when hypoxia is present. Pain from acute MI's may be intense and requires prompt administration of analgesia. Morphine sulfate is the medication of choice (2-4 mg every 5-15 minutes). Reducing the myocardial ischemia also helps reduce pain, so oxygen therapy and nitrates are main components of the therapy. The vasodilation effects of morphine and the nitroglycerin improve coronary blood flow and reduce myocardial ischemia. 2. Incorrect: Heparin is not part of the protocol within the guidelines and is not recommended at this time. 5. Incorrect: Furosemide is not part of the protocol within the guidelines and is not indicated at this time. Question: The nurse is caring for a client on the psychiatric unit with a diagnosis of obsessive- compulsive disorder. The client has frequent hand washing rituals. Which nursing interventions would be advisable for this client? You answered this question Correctly 3. Provide a flexible schedule for the client. 4. Remove all soap and water sources from the client's environment. 1., 2. & 5. Correct: Initially meet the client's dependency needs as required to keep anxiety from escalating. Anything that increases the client's anxiety tends to increase the ritualistic behavior. Positive reinforcement for nonritualistic behavior takes the focus off of the ritual. A lack of attention to ritualistic behaviors can help to decrease the ritual. By creating a regular schedule when the client goes to the bathroom, (where the handwashing ritual occurs most frequently) allows the client a structured but limited time for the ritual. This can help give the client a sense of control of the maladaptive behavior until the client can start setting own limits on the behavior and develop more adaptive coping mechanisms. 3. Incorrect: A structured schedule is needed for this client. If the client is allowed to perform the maladaptive behavior whenever desired, the client will not begin to problem solve ways to limit the ritual nor lessen the anxiety associated with the ritualistic behavior. The set schedule helps the client to develop trust with the nurse, knowing that time will be allowed for the behavior until better coping skills are developed. 4. Incorrect: Sudden and complete elimination of all avenues for dependency would create intense anxiety in the client. This increased anxiety would only serve to increase the ritualistic behavior. When time is not allowed for the ritual, the client fears that something bad is happening and the anxiety escalates. Question: A nurse from an adult unit was reassigned to the pediatric unit. Which client would be least appropriate to assign to this nurse? You answered this question Incorrectly 1. Ten year old with 2nd and 3rd degree burns. 2. Five year old that was in a MVA and has a femur fracture. 4. Two month old with bronchopulmonary dysplasia being admitted for reflux. 3. Correct: The least appropriate client to assign the nurse from the adult unit would be the suspected sexual abuse. Caring for an abused child requires skill that must be developed from understanding the dynamics of abuse as well as working with a certain developmental level. 1. Incorrect: A nurse on an adult unit should understand classification of burns and associated care for the burn client. The pediatric burned client would be a similar to the condition adults might acquire, and the nurse’s skill level could transfer to these clients. 2. Incorrect: The nurse who works on an adult unit should understand the concepts for caring for a client with a fracture. The pediatric client with the fracture would be a similar condition adults might acquire, and the nurse’s skill level could transfer to these clients. 4. Incorrect: The 2 month old with BPD is different, but the concept and care of reflux is similar to that in adult clients. Question: The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin? You answered this question Incorrectly 1. 8:30 AM 3. 1:30 PM 4. 4:00 PM 2. Correct: 11:00 AM: Regular insulin peaks 2-3 hours after administration. Clients are at greatest risk for hypoglycemia when insulin is at its peak. 1. Incorrect: 8:30 AM: Rapid acting insulin will begin peaking in 30 minutes. 3. Incorrect: 1:30 PM: Intermediate acting insulin begins peaking at 4 hours. So at 1:30 PM this would be a time of worry. 4. Incorrect: 4:00 PM: At 4 PM you would still be worried about intermediate acting insulin. But you would also be worried about long acting insulin as well. Which starts to peak at 6 hours. Question: A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client’s room. What priority action should the supervising nurse take? You answered this question Correctly 1. Tell the new nurse to recheck the drug reference book before administering the medication. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication. 2. Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness. 1. Incorrect: There is nothing in the stem about a problem with the medication dose or route. 3. Incorrect: There is nothing in the stem about a problem with the medication dose or route. 4. Incorrect: This is an appropriate action. However, it is not the priority over ensuring that the new nurse knows how to appropriately prepare the medication for this client. Question: A nurse educator is explaining the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to a group of nursing students. What points about HIPAA should the nurse educator include? You answered this question Correctly 1. Primary healthcare providers employed at the facility where a client receives treatment can legally access any client's health information at any time. 5. Unlicensed assistive personnel employed where a client receives treatment can legally access any client's health information at any time. 2. , 3. & 4. Correct: HIPAA is federal legislation enacted to protect client health information and privacy. Any information the client reveals to healthcare personnel must be kept confidential. Clients have the right to access their personal healthcare records and to obtain copies of the records. A client’s health information can be revealed only with the client’s permission, or when a healthcare provider or facility is required to do so by law. 1. Incorrect: Healthcare personnel do not have the right to access a client’s medical records or health information without treatment necessity. 5. Incorrect: Unlicensed assistive personnel do not have the right to access a client's medical record or health information. Question: The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients would be appropriate for the nurse to assign to the LPN/VN? You answered this question Incorrectly 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes. 1., 2., & 3. Correct These clients are stable and require predictable care that can be done appropriately by the LPN/VN. 4. Incorrect: This client has adrenal insufficiency. Primary adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed generally from autoimmune disorders. Secondary adrenal insufficiency can be caused by such things as abrupt stoppage of corticosteroid medications and surgical removal of pituitary tumors. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones may be lacking. This puts the client at risk for fluid volume deficit (FVD) and shock. This requires the higher level assessment skills of the RN. 5. Incorrect: A newly diagnosed client may be unstable and would require assessment, care plan development and teaching for the newly diagnosed diabetic which cannot be performed by the PN. Question: Which assessment finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? You answered this question Incorrectly 1. Fatigue 3. Neutropenia 4. Diarrhea 2. Correct: