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

Unwanted printed health information can be discarded in a trash can.

Information regarding client health can be e-mailed if encrypted.

Members of a health care team can share a computer password.

A client is restricted from accessing his own medical records.

Answer and Explanation

The Correct Answer is B

The correct answer is B.

Information regarding client health can be e-mailed if encrypted. The nurse should follow the Health Insurance Portability and Accountability Act (HIPAA) guidelines to protect client privacy and confidentiality. According to HIPAA, health information can be transmitted electronically if it is encrypted or otherwise secured.

Unwanted printed health information should be shredded or disposed of in a secure bin, not a trash can. Members of a healthcare team should not share a computer password or leave a computer unattended when accessing client information. A client has the right to access his own medical records and request amendments or corrections.

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Correct Answer is C

Explanation

The correct answer is C. Identifying the client's perception of the changes in her physical appearance is essential for developing a plan of care that addresses her psychosocial needs and promotes her self-esteem and body image. The client may experience grief, anger, depression, anxiety, or guilt after losing her breasts, which can affect her quality of life and recovery. The nurse should explore how the client feels about herself and her sexuality, and provide emotional support and empathy. The other actions are also important, but they are not as a priority as understanding how the client views herself.

A. Blood pressure B. Mental confusion C. Cold, clammy skin D. Sodium level E. Pain F. Heart Rate G. Serum amylase level H. Respiratory status I. Urine output J. Temperature

Correct Answer is ["A","B","C","F","G","I","J"]

Explanation

A.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2.This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

B.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C.The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

D.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.

E.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

F.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

G.The serum amylase level is significantly elevated on both days, with a sharp increase from 498 units/L to 1,058 units/L. This finding indicates potential pancreatitis or pancreatic injury, which can lead to serious complications. Given the clinical picture of worsening abdominal pain and elevated lipase (which also increased to 1,283 units/L), it is crucial to report this finding to the provider immediately.

H.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

I.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

J.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

These findings indicate that the client may have severe acute pancreatitis, which can lead to systemic complications such as hypovolemia, shock, hypocalcemia, respiratory failure, and multiorgan failure.

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

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following a total bilateralmastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions?

Correct Answer is C

Explanation

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Correct Answer is ["A","B","C","F","G","I","J"]

Explanation

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