Video

Free preview · Original latest version

Sample questions from Video

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In a pediatric clinic, the parent of a 4-year-old asks whether the nurse can record a video of the child's seizure-like movements on a personal phone for the provider to review. The child is alert, has stable vital signs, and no episode is occurring. What is the nurse's best response?

   • A.Tell the parent that video recording is not permitted in any clinical setting.
   • B.Explain that the parent may choose to record an episode on a personal device for the child's provider, but should avoid including other clients or staff.
   • C.Record a video on the clinic's device and upload it to the child's medical record without further discussion.
   • D.Ask the parent to record any future episode and send the video to the nurse's personal phone.

   Rationale: The parent may use a personal device to document an episode for the child's care, provided the recording does not violate others' privacy; the nurse should not receive protected health information through a personal phone. Sending a video to the nurse's personal device creates a privacy and security risk. Recording on a clinic device requires following organizational policy and obtaining appropriate consent, and a blanket prohibition is not accurate. Protecting confidentiality while supporting useful clinical information is the key management-of-care principle.

2. 2.At change of shift on a medical unit, a 68-year-old client with heart failure has new confusion, a respiratory rate of 30/min, oxygen saturation of 88% on room air, and a blood pressure of 104/66 mm Hg. Three other clients are stable: one needs discharge teaching, one requests pain medication for pain rated 6/10, and one needs assistance to the bathroom. Which client should the nurse assess first?

   • A.The client with heart failure and new confusion and hypoxemia
   • B.The client needing assistance to the bathroom
   • C.The client requesting pain medication
   • D.The client who is waiting for discharge teaching

   Rationale: New confusion with tachypnea and hypoxemia may signal acute respiratory compromise and requires immediate assessment and intervention. Discharge teaching and assistance to the bathroom can wait while the unstable client is evaluated. Pain should be addressed promptly, but the available cues do not indicate a more immediate threat than impaired oxygenation. Prioritize an acute change in airway, breathing, or circulation over routine needs.

3. 3.During a home visit, a 76-year-old client with atrial fibrillation takes warfarin and reports a fall yesterday. The client is alert, has a small bruise, denies pain, and has a blood pressure of 128/74 mm Hg, heart rate of 92/min, and oxygen saturation of 97% on room air. The client asks the visiting nurse to review a video of the fall recorded by a home camera. Which actions should the nurse take? Select all that apply.

   • A.Reassure the client that evaluation is unnecessary because the vital signs are stable and there is only a small bruise.
   • B.Assess for head impact, headache, vomiting, weakness, or other signs of bleeding.
   • C.Arrange prompt medical evaluation because a fall while taking warfarin can cause occult bleeding.
   • D.Advise the client to skip the next warfarin dose without contacting the prescriber.
   • E.Review the video if the client consents and do so in a way that protects the client's privacy.

   Rationale: Assessment for head injury and bleeding is essential because anticoagulation increases the risk of serious occult hemorrhage even when initial vital signs are stable. Prompt medical evaluation is appropriate after a fall on warfarin. Reviewing the client's video may add useful information when the client consents and privacy is maintained. The nurse should not independently hold warfarin, and stable vital signs do not rule out internal bleeding.

4. 4.A provider prescribes a continuous heparin infusion for a 52-year-old client with a new pulmonary embolism in the emergency department. The client's weight is 82 kg, the baseline aPTT is 31 seconds, and the infusion pump displays a dose that differs from the facility's weight-based protocol. What should the nurse do first?

   • A.Reduce the infusion rate by half and notify the provider after the first aPTT result.
   • B.Ask an experienced nursing assistant to compare the pump setting with the protocol.
   • C.Clarify the discrepancy with the provider and verify the dose with another qualified clinician before starting the infusion.
   • D.Start the infusion at the prescribed rate and recheck the aPTT in 6 hours.

   Answer and rationale are in the full material.

5. 5.In a long-term care facility, an 88-year-old resident with dementia has a signed advance directive declining tube feeding if the resident becomes unable to recognize family. The resident is now unable to recognize family, has poor oral intake, and the adult child demands that a feeding tube be inserted immediately. What is the nurse's best action?

   • A.Ask the provider to insert the tube because the adult child is requesting treatment.
   • B.Tell the adult child that the directive means no food or fluids may be offered.
   • C.Delay notifying the provider until the resident's weight decreases further.
   • D.Review the directive with the provider and facilitate a goals-of-care discussion that includes the legally authorized decision-maker.

   Answer and rationale are in the full material.