When should the charge nurse intervene based on the observed behavior?

Correct Answer: B

Rationale: The correct answer is B because it violates patient confidentiality. Reading a client's history and physical in a public area breaches the client's privacy rights. The other choices do not directly compromise patient confidentiality. A involves discussing a cure for AIDS, which is not a breach of confidentiality. C involves sharing personal experiences with the client, and D involves discussing a client's history of drug abuse in a visitor's lounge, which may not be overheard by the client or staff directly involved in the client's care.

Correct Answer: B

Rationale: The correct answer is B: Weight gain. Olanzapine is known to cause metabolic side effects, including weight gain. This is important to monitor as it can lead to various health issues such as diabetes and cardiovascular problems. Hypertension (A), hypoglycemia (C), and bradycardia (D) are not commonly associated with olanzapine use, making them less likely side effects to monitor in this case.

Correct Answer: D

Rationale: The correct answer is D: Vital signs. After paracentesis, monitoring vital signs is crucial as fluid removal can lead to changes in blood pressure, heart rate, and overall fluid balance. Hypotension or tachycardia may indicate hypovolemia or shock. Pedal pulses (A) are important but not as critical post-paracentesis. Breath sounds (B) are important for respiratory assessment but not directly related to fluid removal. Gag reflex (C) is unrelated to paracentesis and not a priority post-procedure.

Correct Answer: B

Rationale: The primary action of amlodipine is to reduce blood pressure by relaxing and dilating blood vessels, leading to improved blood flow and lower blood pressure. This is achieved by blocking calcium channels in the blood vessels. Increasing heart rate (A), lowering cholesterol levels (C), and decreasing blood sugar levels (D) are not the primary actions of amlodipine and are not directly related to its mechanism of action in treating hypertension.

Correct Answer: C

Rationale: Desmopressin is a synthetic form of vasopressin used to replace the hormone in diabetes insipidus. The primary purpose is to decrease urine output by increasing water reabsorption in the kidneys, thereby reducing excessive urination and preventing dehydration. Choice A is incorrect as desmopressin actually decreases urine output. Choice B is incorrect as desmopressin does not directly affect blood sugar levels. Choice D is incorrect as desmopressin does not primarily lower blood pressure.

Correct Answer: B

Rationale: The primary purpose of prescribing calcium acetate for a patient with CKD is to reduce phosphate levels. Calcium acetate acts as a phosphate binder, preventing the absorption of dietary phosphate in the intestines. Elevated phosphate levels in CKD can lead to complications such as mineral and bone disorders. Treating hyperkalemia (A) involves other medications like potassium binders, not calcium acetate. Lowering blood pressure (C) typically involves antihypertensive drugs. Increasing hemoglobin levels (D) is usually managed with erythropoiesis-stimulating agents in CKD patients. Therefore, option B is the correct answer for the primary purpose of prescribing calcium acetate in CKD patients.

Correct Answer: C

Rationale: The correct answer is C: Respiratory depression. Morphine sulfate is an opioid analgesic that can suppress the respiratory drive, leading to respiratory depression, which can be life-threatening. Monitoring respiratory status is crucial to prevent complications. Incorrect choices: A: Diarrhea - While constipation is a common side effect of opioid use, diarrhea is not a significant concern compared to respiratory depression. B: Hypertension - Morphine can cause hypotension rather than hypertension, so monitoring blood pressure for hypertension is not the priority. D: Increased urine output - Morphine can actually cause urinary retention, so increased urine output is not a key side effect to monitor.

Correct Answer: B

Rationale: The correct answer is B because it violates patient confidentiality. Reading a client's history and physical in a public area breaches the client's privacy rights. The other choices do not directly compromise patient confidentiality. A involves discussing a cure for AIDS, which is not a breach of confidentiality. C involves sharing personal experiences with the client, and D involves discussing a client's history of drug abuse in a visitor's lounge, which may not be overheard by the client or staff directly involved in the client's care.

Correct Answer: A

Rationale: The correct answer is A: Continuous tube feeding at 65 ml/hr via gastrostomy. After a CVA, dysphagia, hypoactive bowel sounds, and a firm, distended abdomen indicate a risk for aspiration and bowel obstruction. Continuous tube feeding may worsen these issues. Option B provides nutrition intravenously, bypassing the gastrointestinal tract. Option C helps decompress the stomach. Option D is a medication to help with GI motility. Therefore, the nurse should question option A due to the risk of complications post-CVA.