The newly licensed RN overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed RN would be implemented first?

Monitor the nurses closely for further occurrences.

Advise them to cease their communication.

Inform the nurse manager of the conversation.

Submit an occurrence or variance report.

Answer and Explanation

The Correct Answer is B

Choice A reason: Monitoring for further occurrences is passive and doesn’t address the immediate breach of confidentiality. Advising to stop the conversation protects the client, making this incorrect, as it delays the nurse’s priority of halting the unethical discussion promptly.

Choice B reason: Advising the nurses to cease their communication is the first action to stop the breach of client confidentiality in a public setting. This aligns with ethical and privacy standards, making it the correct initial step for the newly licensed RN to take.

Choice C reason: Informing the manager is important but secondary to stopping the conversation to prevent further disclosure. Advising to cease is immediate, making this incorrect, as it’s not the first action the RN should take to address the confidentiality breach.

Choice D reason: Submitting a report follows stopping the conversation and notifying the manager. Advising to cease is the first step, making this incorrect, as it delays the RN’s priority of immediately halting the nurses’ inappropriate discussion about the client.

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Correct Answer is ["B","F"]

Explanation

Choice A reason: Potassium concentration should be 10-20 mEq/100mL, not 1 mEq/10mL, to avoid irritation. Using an IV controller is correct, making this incorrect, as it’s an unsafe dilution compared to the nurse’s best practices for safe parenteral potassium administration.

Choice B reason: Checking IV access for blood return post-infusion ensures the potassium was delivered correctly, preventing extravasation. This aligns with IV therapy safety, making it a correct best practice the nurse should follow when administering parenteral potassium to the client.

Choice C reason: Pushing potassium as a bolus is dangerous, risking cardiac arrhythmias; it must be infused slowly. IV controller use is correct, making this incorrect, as it’s unsafe compared to the nurse’s best practices for administering potassium to a hypokalemic client.

Choice D reason: Hand veins are unsuitable for potassium, which is irritating and requires larger veins. Checking blood return is correct, making this incorrect, as it risks complications compared to the nurse’s best practices for safe potassium administration in the client.

Choice E reason: Keeping the client NPO is unnecessary for potassium administration, which addresses hypokalemia, not digestion. IV controller use is correct, making this incorrect, as it’s irrelevant to the nurse’s best practices for delivering parenteral potassium safely to the client.

Choice F reason: Using an IV controller ensures a safe, steady infusion rate for potassium, preventing cardiac complications. This aligns with medication safety protocols, making it a correct best practice the nurse should employ when administering parenteral potassium to the hypokalemic client.

A. Hypertension, tachycardia, and fever. B. Hypotension, bradycardia, and hypothermia. C. Restlessness, irritability, and generalized weakness. D. Headache, deteriorating level of consciousness, and twitching.

Correct Answer is D

Explanation

Choice A reason: Hypertension and tachycardia may occur in dialysis but aren’t specific to disequilibrium syndrome, which causes neurological symptoms. Headache and twitching are key, making this incorrect, as it’s less precise than the nurse’s expected manifestations of disequilibrium syndrome.

Choice B reason: Hypotension may occur in dialysis, but bradycardia and hypothermia aren’t typical of disequilibrium syndrome, which affects the brain. Deteriorating consciousness is correct, making this incorrect, as it doesn’t align with the nurse’s assessment for this complication.

Choice C reason: Restlessness and weakness are vague and less specific than headache and twitching, which indicate cerebral edema in disequilibrium syndrome. This is incorrect, as it’s not the primary manifestation the nurse would assess in the dialysis client.

Choice D reason: Headache, deteriorating consciousness, and twitching indicate disequilibrium syndrome due to rapid osmotic shifts during hemodialysis. This aligns with neurological assessment, making it the correct set of manifestations the nurse would monitor in the client at risk.

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The newly licensed RN overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed RN would be implemented first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

Correct Answer is ["B","F"]

Explanation

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

Correct Answer is D

Explanation

A child has a 2-day history of vomiting, hypoactive bowel sounds, and an irregular pulse. Electrolyte values are sodium, 130 mEq/L; potassium, 3.3 mEq/L; calcium, 9.5 mg/dL; and HCO3, 30 mEq/L. Which of the following imbalances is the child most likely to have? (Select all that apply)

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client’s understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2°F (38.5°C). Which nursing action is most appropriate?

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

The laboratory notifies the night nurse that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not inform the practitioner because of the patient’s code status. In doing so, the nurse is negligent for which action?

The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Which situations are early signs of an ethical dilemma? (Select all that apply)