A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

A client who has dementia and is experiencing paranoia

A client who has a UTI and reports itching after receiving a dose of cefaclor PO

A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr

A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III

Answer and Explanation

The Correct Answer is D

A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.
B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.
C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.
D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.

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Correct Answer is A

Explanation

A. Logging the previous user out of the system immediately ensures the client's health information is no longer visible, protecting the client's privacy according to HIPAA guidelines.
B. Offering to conduct an in-service on client confidentiality is a proactive measure but does not address the immediate privacy issue.
C. Reporting the incident to the charge nurse is appropriate but does not prevent unauthorized viewing of the client's information immediately.
D. Completing an incident report is necessary to document the breach, but it should occur after protecting the client’s privacy by logging out.

A. The client's temperature is 39.5° C (103.1° F). B. Contact the client's provider for a prescription for a sputum culture. C. The client reports increasing shortness of breath. D. The client has COPD.

Correct Answer is D,C,A,B

Explanation

Rationale

Situation: The client has COPD and is experiencing an acute exacerbation.
Background: The client has a history of COPD and has been experiencing increasing shortness of breath.
Assessment: The client's temperature is 39.5°C (103.1°F) and is experiencing shortness of breath.
Recommendation: Contact the client's provider for a prescription for a sputum culture.

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A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

Correct Answer is D,C,A,B

Explanation

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