A nurse is caring for four clients. Which of the following clients should the nurse assess first?

A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness

A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL

A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10

A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Answer and Explanation

The Correct Answer is A

a.   The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b.   While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c.   Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d.   The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.

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Correct Answer is A

Explanation

a. This statement demonstrates an understanding of the importance of protecting personal health information by encrypting it when transmitting electronically, ensuring confidentiality.
b. Using another nurse's password violates client confidentiality and compromises security protocols.
c. Discarding personal health information documents in the trash without proper disposal methods can lead to unauthorized access and breach of confidentiality.
d. Posting a client's vital signs in their room could potentially compromise their privacy, as it may be viewed by unauthorized individuals.

A. “A nurse can disclose information to a family member with the client’s permission” B. “A nurse is responsible for informing clients about treatment options” C. "A nurse can apply restraints on a PRN basis” D. “A nurse can administer medications without consent to a client as part of a research study”

Correct Answer is A

Explanation

- Rationale for A: Client confidentiality is a fundamental part of nursing ethics and legal practice. A nurse may disclose information to a family member only if the client has given permission, ensuring respect for the client's autonomy and privacy.
- Rationale for B: While it is true that nurses play a crucial role in patient education, the primary responsibility for informing clients about treatment options lies with the attending physician or healthcare provider.
- Rationale for C: The use of restraints is highly regulated in healthcare settings. Restraints can only be applied based on specific criteria and orders that are not on a PRN (as needed) basis, to protect the safety and rights of the client.
- Rationale for D: Administering medications without consent, even as part of a research study, is unethical and illegal unless specific and stringent consent procedures are followed, which include informed consent and approval by an institutional review board (IRB).

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A nurse is caring for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the Inservice?

Correct Answer is A

Explanation

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