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A nurse is collaborating with the interprofessional team and reviewing a client's electronic medical record of a post-operative client.

Exhibits

Click to highlight the findings that the nurse should recommend be addressed by the case manager. To deselect a finding, click on the finding again.

Nurses' Notes

1315:

Client is postoperative following an open cholecystectomy. Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment.

Plan of Care

1300:

Case management referral for discharge planning. Client will need home health referral for dressing changes. Client to follow up with the provider at the clinic in one week.

Client's partner is at bedside

dressing intact

small amount of serosanguineous drainage on dressings

reports pain as 5

Client requests a dose of their pain medication

expresses concern regarding the cost of prescription medications

unable to find transportation

home health referral

Answer and Explanation

The Correct Answer is ["D","E","F","G","H"]

Rationale

Client reports pain as 5 on a scale of 0 to 10. The case manager can work with the healthcare team to ensure adequate pain management strategies are in place.
Client requests a dose of their pain medication. This indicates ongoing pain and the need for effective pain management.
Client expresses concern regarding the cost of prescription medications. The case manager can assist with identifying affordable medication options or connecting the client with financial assistance programs.
Client reports being unable to find transportation to follow-up appointment. The case manager can help arrange transportation or connect the client with community resources that can provide transportation assistance.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Notifying the nurse manager is important, but it is not the immediate priority when a family member has fainted.
B. Completing an incident report is necessary for documentation but should occur after addressing the immediate medical concern.
C. Obtaining the family member's health history is not pertinent at this moment as the priority is to assess their current condition.
D. Checking the family member's vital signs is the first action to determine their immediate health status and any necessary interventions to provide appropriate care.

A. Identify clients by room number instead of name in printed materials for student use. B. Log assistive personnel into unit computers for documentation purposes. C. Place the client's name on the cover sheet when faxing protected health information. D. Conduct change-of-shift report in a designated staff-only area.

Correct Answer is D

Explanation

A. Identifying clients by room number instead of name does not adequately protect client confidentiality, as room numbers can still be linked to specific patients.
B. Logging assistive personnel into unit computers for documentation undermines security measures, as each user should have their unique login credentials.
C. Placing the client's name on the cover sheet when faxing protected health information violates confidentiality and can lead to unauthorized access to sensitive data.
D. Conducting change-of-shift reports in a designated staff-only area ensures that client information is not overheard by unauthorized individuals, maintaining confidentiality.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client for an elective surgical procedure. During the client interview, one of the client's family members faints. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following information should the nurse include?

Correct Answer is D

Explanation

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?

A nurse in a long-term care facility is caring for a client who received a superficial burn from a heating pad that malfunctioned. After completing an incident report, which of the following actions should the nurse take?

A nurse enters a client's room and sees smoke coming from a wall outlet. After removing the client from the room, which of the following actions should the nurse take next?

A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

A nurse is observing an assistive personnel (AP) provide care to a group of clients. Which of the following actions by the AP requires intervention by the nurse?

A nurse is caring for a client who has a terminal illness and states that they wish to discontinue their enteral feedings. The nurse responds by saying, "You have a right to refuse treatment." This response by the nurse demonstrates which of the following ethical principles?

A nurse working on an acute care unit is supervising a team of assistive personnel (AP). Which of the following actions by the nurse is an example of laissez-faire leadership?