A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

"Do you understand HIPAA regulations?"

"This discussion is only appropriate in a private area."

"Please stop this discussion."

"Did you know you can be liable if you breach confidentiality?"

Answer and Explanation

The Correct Answer is C

A. While understanding HIPAA regulations is important, addressing the immediate inappropriate behavior takes precedence.

B. While directing the conversation to a private area is appropriate, stopping the discussion immediately is the priority.

C. The priority is to stop the discussion immediately to prevent further breach of confidentiality.

D. While informing about potential liability for breaching confidentiality is important, addressing the immediate behavior is the priority.

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Correct Answer is C

Explanation

A. Dependent edema is a sign of fluid overload or right-sided heart failure but is not immediately life-threatening.
B. A pericardial friction rub is a characteristic finding of pericarditis but does not indicate imminent compromise.
C. A paradoxical pulse (pulsus paradoxus) can indicate cardiac tamponade, a life-threatening complication of pericarditis. Prompt recognition and intervention are critical.
D. Substernal chest pain is a common symptom of pericarditis and should be addressed, but it is not as immediately dangerous as signs of cardiac tamponade.

A. The provider should renew the prescription for restraints every 48 hr. B. The nurse should pad the bony prominences. C. The nurse should tie the restraints using a square knot. D. The nurse should remove the restraints every 2 hr. E. The provider's prescription should include the type of restraint to use.

Correct Answer is ["B","D","E"]

Explanation

A. The provider should renew the prescription for restraints every 24 hours, not 48 hours. This ensures regular evaluation of the need for continued restraint use.

B. Padding bony prominences helps prevent skin breakdown and injury from the restraints.

C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in case of emergency.

D. Restraints should be released every 2 hours (or as specified by the provider) to assess and provide care for the client's needs and to prevent complications such as skin breakdown or circulation impairment.

E. The provider's prescription should specify the type of restraint to be used, the reason for use, the duration, and any other relevant details to ensure appropriate and safe application.

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A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

Correct Answer is C

Explanation

A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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