adult health 1 ati quiz- week 7

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "Information about a client can be disclosed to family members at any time." B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." C. "A client's address would be an example of personally identifiable information." D. "HIPAA is a federal law, not a state law."

A. "Information about a client can be disclosed to family members at any time." Rationale: This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? A. Secure the restraints using a quick-release tie. B. Ensure four fingers fit under the restraints to prevent constriction. C. Secure the restraints to the lowest bar of the side rail. D. Anticipate removing the restraints every 4 hr.

A. Secure the restraints using a quick-release tie. Rationale: The nurse should secure the restraints using a quick-release tie for easy removal in an emergency.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? A. Obtain a pair of slipper-socks for the client. B. Rub the client's feet briskly for several minutes. C. Increase the client's oral fluid intake. D. Place a moist heating pad under the client's feet.

A. Obtain a pair of slipper-socks for the client. Rationale: In cold weather or when the client's feet are cold, he should wear extra socks or slipper socks to help provide warmth and increase his level of comfort.

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? A. Remove the catheter and insert another into a different site. B. Administer an analgesic PO. C. Request a prescription for placement of a central venous access device. D. Administer a local anesthetic.

A. Remove the catheter and insert another into a different site. Rationale: It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Suction two to three times with a 60-second pause between passes. B. Perform chest physiotherapy prior to suctioning. C. Lubricate the suction catheter tip with sterile saline. D. Hyperventilate the client on 100% oxygen prior to suctioning.

A. Suction two to three times with a 60-second pause between passes. Rationale: Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? A. Tell the client to blow her nose gently before the instillation. B. Assist the client to a side-lying position. C. Hold the dropper 2 cm (1 in) above the naris. D. Instruct the client to stay in the same position for 2 min.

A. Tell the client to blow her nose gently before the instillation. Rationale: Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following actions should the nurse take first? A. Inject 10 units of air into the regular insulin vial. B. Inject 20 units of air into the NPH insulin vial. C. Withdraw 10 units of insulin from the regular insulin vial. D. Replace the needle for withdrawal with a safety needle.

B. Inject 20 units of air into the NPH insulin vial. Rationale:The first action the nurse should take is to inject 20 units of air into the NPH insulin vial because this insulin is the intermediate-acting insulin, which will be drawn up last in order to avoid contaminating the regular insulin with NPH insulin

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.) A. Bradycardia B. An increase in neutrophils C. An increase in RBCs D. An increase in platelets E. Localized edema

B. An increase in neutrophils E. Localized edema Rationale: Bradycardia is incorrect. Tachycardia, not bradycardia, is an indication of infection.An increase in neutrophils is correct. During the inflammatory stage of wound healing, neutrophils move into the interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroy micro-organisms.An increase in RBCs is incorrect. An increase in the RBC count reflects polycythemia, not infection.An increase in platelets is incorrect. An increase in the platelet count can reflect malignancies, not infection.Localized edema is correct. Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein to pour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulated fluid appears as localized swelling or edema.

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A. Adjust the water temperature to feel hot. B. Apply 4 to 5 mL of liquid soap to the hands. C. Hold the hands higher than the elbows. D. Rub hands and arms to dry.

B. Apply 4 to 5 mL of liquid soap to the hands. Rationale: The nurse should apply 4 to 5 mL of liquid soap to the hands to ensure an adequate amount is available to produce lather and kill microorganisms.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? A. Steatorrhea B. Blood C. Bacteria D. Parasites

B. Blood Rationale: A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.

A nurse is caring for a client who has type I diabetes mellitus and is not following the guidelines for therapy. Which of the following should the nurse consider as contributing factors to the client's nonadherence? (Select all that apply.) A. Gender B. Culture C. Literacy D. Dexterity E. Motivation

B. Culture C. Literacy D. Dexterity E. Motivation Rationale: Gender is incorrect. Evidence-based practice does not support gender as a basis for nonadherence to therapy.Culture is correct. Sociocultural background, beliefs, practices, values, and traditions can significantly affect a client's adherence or nonadherence to therapy. The client's perception of the seriousness of the illness also can affect adherence.Literacy is correct. A client's reading level can significantly affect adherence or nonadherence to therapy. The nurse should monitor the client's ability to read and correctly administer medication.Dexterity is correct. Dexterity, physical strength, endurance, movement, and coordination can affect the client's ability to manipulate equipment for glucose monitoring and medication administration.Motivation is correct. It is important to monitor the client's motivation for following the treatment plan. The client's perception of the seriousness of the illness also can affect adherence

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior? A. He is hard of hearing. B. Pain C. Confusion D. Language barrier

C. Confusion Rationale: Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion.

A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse plan to take first? A. Establish short-term, realistic goals for the client. B. Give the client access to a video about diabetes. C. Determine what the client knows about managing diabetes. D. Evaluate the effectiveness of the client's admission teaching plan.

C. Determine what the client knows about managing diabetes. Rationale: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should find out what the client knows before proceeding with the plan

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use? A. Ask the client to perform a return demonstration of insulin injection. B. Review the action of insulin therapy. C. Explore the client's feelings about dietary modifications. D. Have the client practice blood-glucose monitoring using a glucometer.

C. Explore the client's feelings about dietary modifications. Rationale: This teaching intervention allows the client to express his acceptance of this change and focuses on affective learning.

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? A. Close the fire doors on the unit. B. Activate the fire alarm. C. Move any clients in the immediate vicinity. D. Use a fire extinguisher to put out the fire.

C. Move any clients in the immediate vicinity. Rationale: The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? A. Use a stiff toothbrush to clean the client's teeth. B. Use the thumb and index finger to keep the client's mouth open. C. Turn the client on his side before starting oral care. D. Apply petroleum jelly to the client's lips after oral care.

C. Turn the client on his side before starting oral care. Rationale: Placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking.

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? A. "I will wear gloves when removing food from the freezer." B. "I will try to anticipate and avoid stressful situations when possible." C. "I will complete the smoking cessation program I started." D. "I will take my medications at the first sign of an attack."

D. "I will take my medications at the first sign of an attack." Rationale: Taking medications at the onset of an episode of Raynaud's disease may help to reduce the severity of the manifestations, but it will not prevent the onset of vasoconstriction.

A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse? A. Invasion of privacy B. Assault C. Battery D. False imprisonment

D. False imprisonment Rationale: False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment against medical advice and leave the hospital.

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? A. Dorsal metacarpal vein B. Radial vein in the wrist C. Antecubital vein D. Median vein in the forearm

D. Median vein in the forearm Rationale: The nurse should use the median vein in the forearm because it is distal to other potential venipuncture sites and it avoids areas of flexion. The bones in the forearm provide natural splinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client

A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take? A. Mix the three medications together prior to administering. B. Dilute each medication with 10 mL of tap water. C. Reattach the suction directly after administering the medication. D. Pinch the tube prior to attaching the medication syringe.

D. Pinch the tube prior to attaching the medication syringe. Rationale: After detaching the NG tube from the suction tubing, the nurse should pinch or kink the tube to prevent distention from air entering the tube.