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Questions 164

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Question 1 of 5

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?

Correct Answer: B

Rationale: Discarding a specimen invalidates the 24-hour collection, requiring a restart to ensure accurate results. Adding volume, restarting mid-collection, or relabeling compromise test integrity.

Question 2 of 5

The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, 'I don’t know why this is being reported. I told the health care provider (HCP) that it was an accident.' What is the best response by the nurse?

Correct Answer: C

Rationale: Explaining that reporting is legally mandated for child safety is factual and nonjudgmental. Deferring to CPS, questioning the parent, or doubting their explanation may escalate tension or avoid responsibility.

Question 3 of 5

The nurse is collecting data from a client with a history of alcohol use disorder who had an emergency appendectomy 3 days ago. Which of the following findings would indicate that the client is experiencing delirium tremens? Select all that apply.

Correct Answer: B,C,E

Rationale: Delirium tremens presents with diaphoresis, hallucinations, and tachycardia due to autonomic hyperactivity. Bradypnea and lethargy are not typical; agitation is more common.

Question 4 of 5

The nurse is caring for a client with social anxiety disorder. Which of the following situations would most likely exacerbate the client's symptoms?

Correct Answer: C

Rationale: Speaking publicly, especially to peers, is highly likely to trigger social anxiety due to fear of scrutiny. Crowded stores, moving, and new providers may cause anxiety but are less intense triggers.

Question 5 of 5

The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client’s caregiver?

Correct Answer: A

Rationale: Around-the-clock dosing maintains pain control in cancer, preventing peaks and troughs. Combining with immediate-release opioids is common, dosage changes require provider orders, and tapering is less critical in terminal care.

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