A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?

Weight loss of 1 kg (2.2 lb) in the past 24 hr

Pale, clammy skin

Fatigue when ambulating 152 m (500 ft)

Productive cough with pink, frothy sputum

Answer and Explanation

The Correct Answer is D

A productive cough with pink, frothy sputum is indicative of pulmonary edema, which is a serious manifestation of left-sided heart failure.

It suggests fluid accumulation in the lungs, impairing gas exchange and oxygenation.

Prompt notification of the provider is crucial for appropriate intervention and management of the client's condition.

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Correct Answer is B

Explanation

This response acknowledges the client's concern and offers support and guidance. By demonstrating and encouraging the client to participate in swaddling and cuddling the newborn, the nurse promotes bonding, provides a practical solution for soothing the baby, and empowers the client to actively engage in caring for her child.

A. Giving change-of-shift report to a nurse outside the client's room B. Writing a client's diagnosis on the message board in the client's room C. Discussing a client's prognosis with an assistive personnel who is caring for the client D. Discarding worksheets containing client information in a wastebasket

Correct Answer is A

Explanation

Giving change-of-shift report to a nurse outside the client's room helps to maintain client confidentiality. By discussing sensitive client information in a private and secure area, such as a designated report room or a location where other clients or visitors cannot overhear, the nurse ensures that the client's personal and medical information is not disclosed to unauthorized individuals.

Writing a client's diagnosis on the message board in the client's room can potentially expose sensitive medical information to anyone who enters the room, including visitors or other healthcare providers who are not directly involved in the client's care.

Discussing a client's prognosis with an assistive personnel who is caring for the client may violate the principle of need-to-know confidentiality. While it is important for healthcare team members to collaborate and communicate about client care, sensitive information should only be shared on a need-to-know basis.

Discarding worksheets containing client information in a wastebasket without proper shredding or disposal methods can potentially expose client information to unauthorized individuals who may come across the discarded documents. Proper procedures for document disposal, such as shredding or using secure disposal containers, should be followed to protect client confidentiality.

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A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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