Nursing Elites

1. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider?

• A. Decreased white blood cell count
• B. Pruritus and muscle aches
• C. Elevated liver function tests
• D. Vomiting and diarrhea

Correct answer: C

Rationale: The correct answer is C: Elevated liver function tests. When administering antivirals, especially orally, monitoring liver function tests is crucial as it may indicate liver toxicity. This finding should be reported promptly to the healthcare provider to prevent further complications. Choice A, decreased white blood cell count, may be expected with certain antivirals but is not the most critical finding in this scenario. Pruritus and muscle aches (choice B) are common side effects of antivirals and do not require immediate reporting. Vomiting and diarrhea (choice D) are also common side effects that may not be as concerning as elevated liver function tests.

2. When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)

• A. Protect the medication from light exposure
• B. Monitor for changes in level of consciousness
• C. Observe for onset of generalized bruising or bleeding
• D. Perform ongoing assessment of respiratory status

Correct answer: D

Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.

3. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today?

• A. Assist the client in identifying goals for the day
• B. Encourage the client to participate in a team sport for one hour
• C. Schedule the client for a group session that focuses on self-esteem
• D. Help the client develop a list of daily affirmations

Correct answer: A

Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.

4. A male client who fell into the lake while fishing and was submerged for about 3 min was successfully resuscitated by his friends. He was brought to the Emergency Department for evaluation and was admitted for a 24-hour uneventful hospital stay. What follow-up instruction should the nurse give?

• A. Avoid smoke-filled environments
• B. Seek medical care promptly if a fever develops
• C. Increase oral fluids if a cough becomes productive
• D. Schedule frequent rest periods

Correct answer: B

Rationale: After being submerged in water, the client should be instructed to seek medical care promptly if a fever develops since complications may arise later. Choices A, C, and D are not directly related to the potential complications from submersion in water and are therefore incorrect. Avoiding smoke-filled environments, increasing oral fluids for a productive cough, and scheduling frequent rest periods are not the priority concerns in this scenario.

5. Which situation is a violation of client confidentiality, as described in the Health Insurance Portability and Accountability Act (HIPAA)?

• A. A sign-in sheet kept at the front desk listing clients' last names and the time of their arrival
• B. A nurse's handwritten notes from a telephone report discarded in the office wastebasket
• C. A computer monitor screen located at the nurse's station in a high-traffic area
• D. Privileged Health Information (PHI) given to an ambulance driver for the transfer of a client

Correct answer: C

Rationale: Choice C is a violation of client confidentiality as it exposes patient information to unauthorized individuals due to its location in a high-traffic area. HIPAA regulations require that electronic protected health information (ePHI) be safeguarded against unauthorized access, making the situation described in choice C a violation. Choices A, B, and D do not directly involve the exposure of patient information to unauthorized individuals. While choices A and B may pose some risks, they are not as severe as the direct exposure described in choice C. Choice D involves sharing information with an ambulance driver for a legitimate purpose, which does not violate HIPAA if done securely and in compliance with regulations.

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