A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality?

A nurse is caring for a newly admitted older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to the medical-surgical unit from the emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by an adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

The client is soft-spoken, speaks almost in a whisper, and does not make eye contact with the nurse.

The client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." The client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.

A nurse is caring for a newly admited older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.

Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hours PRN for pain.

The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this alert care incident?

A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure.

Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assisting with planning an in-service for staff members about active shooter protocols. Which of the following information should the nurse recommend including?

A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information?

A nurse is reinforcing teaching with a parent of a newborn about home safety precautions.

Which of the following statements by the parent indicates an understanding of the teaching?