The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.

Exhibits

For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Administer acyclovir.

Administer lorazepam.

Initiate 1:1 supervision.

Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Potential Provider Prescription	Expected or Unexpected?	Explanation
Administer acyclovir.	Unexpected	Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause.
Administer lorazepam.	Expected	Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention.
Initiate 1:1 supervision.	Expected	The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.	Expected	The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration.

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Correct Answer is C

Explanation

Choice A rationale:

Discussing a client’s information with staff who have provided care in the past is not appropriate unless it is necessary for the client’s current care.

Choice B rationale:

The provider does not need to give consent to discuss health information with the client’s family. The client is the one who must give consent.

Choice C rationale:

This statement is correct. A client retains the legal right to privacy of health information even after they have died.

Choice D rationale:

A provider may not speak to a client’s employer regarding a substance use disorder without the client’s consent.

A. "Having a newborn must be stressful. Do you have other children?". B. "Tell me about your baby. Where is she now?". C. "Do you have a friend who could help you?". D. "Have you discussed this with your partner?".

Correct Answer is B

Explanation

Choice A rationale:

While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.

Choice B rationale:

This response is the priority as it assesses the immediate safety of the baby.

Choice C rationale:

While support is important, the immediate safety of the baby is the priority.

Choice D rationale:

While communication with the partner is important, the immediate safety of the baby is the priority.

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The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

Correct Answer is C

Explanation

A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?.

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?.

A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the redirection technique? .

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first? .

A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement? .

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).

A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?.

A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep? .

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.

Exhibits

For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.