a nurse in the emergency room enters a clients care area to start an iv she finds a man sitting on the table hunched over and attempting to take deep

NCLEX-RN

Saunders NCLEX RN Practice Questions

1. A client in the emergency room enters the care area to start an IV. He finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, 'my chest hurts so much!' His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the client?

A. Bring the IV kit and quickly start an IV
B. Assess his breathing and provide oxygen, if necessary
C. Administer medication to control chest pain
D. Talk with his wife and find out why she is crying

Correct answer: B: Assess his breathing and provide oxygen, if necessary

Rationale: In the above scenario, the first action of the nurse should be to assess the client's airway and breathing. It is crucial to address respiratory status first, as the client appears to be experiencing difficulty breathing. Providing oxygen if necessary can help support oxygenation and alleviate potential respiratory distress. Administering medication for chest pain or starting an IV can come after ensuring adequate oxygenation. Talking with the client's wife, though important for emotional support, is not the priority when the client's respiratory status needs to be assessed and managed promptly.

2. Choose the BEST answer. To ensure adequate protection for legal issues, offices should maintain patients' charts for:

A. 10 years
B. Forever
C. Until the age of majority
D. 2 years after the patient was last seen in the office

Correct answer: Forever

Rationale: The correct answer is 'Forever.' Maintaining patients' charts indefinitely ensures comprehensive legal protection by having all relevant information available in case of litigation or if patient history needs to be referenced in the future. Choice A, '10 years,' may not be sufficient to cover the entire period within which legal issues may arise. Choice C, 'Until the age of majority,' is not ideal as legal matters may extend beyond this age limit. Choice D, '2 years after the patient was last seen in the office,' is inadequate as legal actions can occur beyond this timeframe, necessitating the need for long-term retention of patient charts.

3. Which of the following reasons would be legal when considering a patient's medical record?

A. Allowing a patient's brother to view her chart to find out her birthdate and address so that he can mail her a card
B. Not allowing a patient to view her own chart because the physician feels this information would be detrimental to her wellbeing
C. Not allowing a patient to view her chart because she is behind on her payments
D. All of the above are legal

Correct answer: Not allowing a patient to view her own chart because the physician feels this information would be detrimental to her wellbeing

Rationale: The correct answer is not allowing a patient to view her own chart because the physician feels this information would be detrimental to her wellbeing. Physicians have a duty to withhold certain health information from patients if disclosing it could potentially harm the patient. In situations where revealing certain information may have a significantly negative impact on the patient's mental or physical health, healthcare providers have the legal right to withhold that information. Allowing a patient's brother to view her chart for non-medical reasons like sending a card is not a valid legal reason for disclosing patient information. Similarly, refusing access based on financial reasons is not a legal ground for restricting access to a patient's medical record as patient care should not be influenced by financial matters.

4. What does an anti-kickback statute prevent?

A. It prevents healthcare workers from providing food or hosting parties to celebrate special occasions at work.
B. It promotes thorough and complete documentation when a client becomes injured.
C. It forbids giving or accepting gifts to promote or provide referrals for certain services.
D. It prevents physicians from ordering treatments that may require nursing care beyond the usual amount.

Correct answer: It forbids giving or accepting gifts to promote or provide referrals for certain services.

Rationale: An anti-kickback statute aims to prevent healthcare providers, clients, consultants, or related organizations from giving or accepting gifts to reward others for referrals of certain services. Choice A is incorrect because providing food or hosting parties at work is not the primary focus of anti-kickback statutes. Choice B is incorrect as it pertains more to documentation practices rather than gift-giving. Choice D is incorrect as it refers to the scope of physician orders and nursing care, not gift exchanges for referrals. The correct answer, as stated, aligns with the purpose of anti-kickback statutes to prevent improper incentives in healthcare relationships.

5. A nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:

A. Psychological abuse
B. Abandonment
C. Material exploitation
D. Physical abuse

Correct answer: A: Psychological abuse

Rationale: The correct answer is A: Psychological abuse. This behavior is classified as psychological abuse, which harms another person through words or threats. The nursing assistant's actions of yelling, making threats, and using food as a form of control fall under psychological abuse. Abandonment (choice B) refers to deserting or leaving a client without care, which is not the case in the scenario. Material exploitation (choice C) involves taking advantage of a person's assets or resources for personal gain, which is not evident here. Physical abuse (choice D) involves causing physical harm, which is not the primary issue in this situation. Therefore, the most appropriate classification for the behavior described in the scenario is psychological abuse.