A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?

The ethics committee will need to approve this request for you.

I will ask the nursing supervisor to obtain the medical records for you.

The healthcare provider will share this information with you.

The client must provide permission to share the records with you.

Answer and Explanation

The Correct Answer is D

Choice A reason:

The ethics committee does not typically handle requests for access to medical records. Their role is more focused on addressing ethical dilemmas and conflicts in patient care, rather than routine administrative tasks like granting access to medical records.

Choice B reason:

Asking the nursing supervisor to obtain the medical records for a family member is not appropriate without the client’s consent. Medical records are confidential and protected under laws such as HIPAA (Health Insurance Portability and Accountability Act), which require patient authorization for disclosure.

Choice C reason:

The healthcare provider cannot share medical information with a family member without the client’s explicit permission. This is to ensure the privacy and confidentiality of the client’s health information.

Choice D reason:

The correct procedure is for the client to provide permission to share their medical records. Under HIPAA, a healthcare provider can only share a patient’s medical information with family members if the patient has given explicit consent. This ensures that the patient’s privacy rights are respected and that their health information is protected.

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Correct Answer is A

Explanation

Choice A reason:

Place a pillow under the client’s head: During a tonic-clonic seizure, it is crucial to protect the client’s head from injury. Placing a pillow or any soft object under the head can help prevent head trauma caused by the convulsions. Ensuring the client’s safety by protecting their head is a primary concern during a seizure.

Choice B reason:

Insert a padded tongue blade into the client’s mouth: This action is incorrect and potentially dangerous. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or jaw. It can also obstruct the airway. The myth that a person can swallow their tongue during a seizure is false, and no object should be placed in the mouth.

Choice C reason:

Apply a face mask for oxygen administration: While providing oxygen can be beneficial after the seizure has ended, during the seizure, the priority is to ensure the client’s safety and prevent injury. Applying a face mask during the active phase of a seizure is not practical and can interfere with managing the seizure safely.

Choice D reason:

Gently restrain the client’s extremities: Restraining the client’s extremities during a seizure is not recommended. Attempting to restrain the movements can cause injury to both the client and the nurse. The focus should be on protecting the client from harm without restricting their movements.

A. Plan a plan of care for a client when postoperative from an appendectomy B. Provide discharge instructions to a confused client’s spouse C. Administer a tap-water enema to a client who is preoperative D. Clean vital signs from a client who is 6 hours postoperative E. Catheterize a client who has not voided in 8 hours

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

Explanation

Choice A reason: Plan a plan of care for a client when postoperative from an appendectomy

Planning a plan of care for a client, especially postoperatively, is a complex task that requires comprehensive assessment and critical thinking skills. This responsibility typically falls within the scope of practice of a registered nurse (RN) rather than an LPN. The RN is trained to develop individualized care plans based on a thorough assessment of the client’s condition, medical history, and specific needs. This ensures that the care plan is holistic and addresses all aspects of the client’s recovery.

Choice B reason: Provide discharge instructions to a confused client’s spouse

Providing discharge instructions, particularly to a confused client’s spouse, involves detailed communication and education. This task is generally performed by an RN, who has the expertise to ensure that the instructions are clear, comprehensive, and tailored to the client’s specific needs. The RN can also assess the spouse’s understanding and provide additional clarification as needed. This ensures that the client receives appropriate care at home and reduces the risk of complications.

Choice C reason: Administer a tap-water enema to a client who is preoperative

Administering a tap-water enema is a task that can be safely delegated to an LPN. LPNs are trained to perform routine procedures such as enemas, which do not require the advanced assessment skills of an RN. This task involves following established protocols and ensuring the client’s comfort and safety during the procedure. By delegating this task to an LPN, the RN can focus on more complex aspects of client care.

Choice D reason: Clean vital signs from a client who is 6 hours postoperative

Obtaining and recording vital signs is a fundamental skill within the LPN’s scope of practice, as it involves routine data collection without interpretation or care‑planning decisions.

Choice E reason: Catheterize a client who has not voided in 8 hours

Catheterization is a procedure that LPNs are trained to perform. This task involves inserting a catheter to relieve urinary retention, which can be a common issue in postoperative clients. LPNs can perform this procedure safely and effectively, following established protocols to minimize the risk of infection and ensure the client’s comfort. Delegating this task to an LPN allows the RN to focus on other critical aspects of client care.

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A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)

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

Explanation

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