Questions 38

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ATI NUR 104 Final Assessment Fundamentals Questions

Extract:

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?


Question 1 of 5

The client has not been taking the medication properly

Correct Answer: C

Rationale:
Tolerance, requiring higher doses for the same effect, explains the need for increased morphine. Addiction involves compulsive use, not dose increase, and other options are unrelated.

Extract:

A nurse is preparing to administer a rectal suppository to a client. In which of the following positions should the nurse place the client for Insertion of the suppository?


Question 2 of 5

Prone position

Correct Answer: B

Rationale: Sim’s position (left side, right knee flexed) facilitates rectal access for suppository insertion. Other positions are less effective.

Extract:

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?


Question 3 of 5

HIPAA is a federal law, not a state law

Correct Answer: D

Rationale: Disclosing information to family without consent violates HIPAA. Other statements are correct regarding HIPAA’s scope and definitions.

Extract:

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?


Question 4 of 5

Identifying the client by name when making a referral for home health services

Correct Answer: B

Rationale: Reporting lab findings to family without consent violates confidentiality. Referrals, discussions with the nurse manager, and provider notifications are permissible for care coordination.

Extract:

A nurse is planning to administer ceftriaxone IM to an adult client. Which of the following actions should the nurse plan to take?


Question 5 of 5

Administer the medication using a Z-track technique

Correct Answer: A

Rationale: The Z-track technique prevents leakage and irritation for ceftriaxone. A longer needle, ventrogluteal site, and 90° angle are appropriate.

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