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 B

Explanation

A. Serum calcium levels are not directly indicative of hypervolemia.

B. A urine specific gravity of 1.001 indicates dilute urine, which is a common finding in hypervolemia as the kidneys attempt to excrete excess fluid.

C. Serum sodium levels within the normal range (e.g., 138 mEq/L) are not indicative of hypervolemia.

D. Urine pH of 6.1 is within the normal range and does not specifically indicate hypervolemia.

A. A client who is 2 days postpartum and whose fundus is 2 fingerbreadths below the umbilicus B. A client who is 1 day postpartum and has not voided in 8 hr C. A client who is 3 days postpartum and has not had a bowel movement since prior to admission D. A client who is 4 days postpartum and has lochia serosa

Correct Answer is B

Explanation

A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.

B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.

C. Not having a bowel movement since prior to admission is not an urgent concern in the

immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.

D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.

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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 checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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