A nurse is reviewing the medical record of a client who has a paralytic ileus.

Exhibits

Select words from the choices below to fill in each blank in the following sentence:

The findings in the client's medical record indicate
dropdown
and
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.

B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.

C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.

D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.

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Correct Answer is B

Explanation

Rationale:

A. This response addresses the client's desire to have family visits but does not directly address the client's concerns about end-of-life care.

B. Asking the client to express their expectations about activities related to the end-of-life allows the nurse to understand the client's wishes and concerns and to provide appropriate support.

C. This response addresses the client's need for pain management but does not directly address the client's concerns about end-of-life care.

D. This response addresses the client's need for spiritual support but does not directly address the client's concerns about end-of-life care.

A. Tell the nurse that permission from the risk manager is required to view the client's record. B. Contact facility security to remove the nurse from the unit. C. Complete an incident report about the breach of confidentiality. D. Remind the nurse that only staff caring for the client may access the client's record.

Correct Answer is D

Explanation

Rationale:

A. Telling the nurse that permission from the risk manager is required to view the client's record is not accurate and may not address the situation appropriately.

B. Contacting facility security to remove the nurse from the unit is not necessary and may not address the situation appropriately.

C. Completing an incident report about the breach of confidentiality may be appropriate later if the situation escalates or if there is no resolution after speaking to the nurse. However, the immediate step is to address the breach directly.

D. Reminding the nurse that only staff caring for the client may access the client's record is the correct action. The nurse should remind the colleague that access to a client's medical record is restricted to those directly involved in their care. This respects patient confidentiality and complies with legal and ethical guidelines.

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A nurse is reviewing the medical record of a client who has a paralytic ileus. Exhibits Select words from the choices below to fill in each blank in the following sentence: The findings in the client's medical record indicate dropdownand dropdown.

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A nurse is reviewing the medical record of a client who has a paralytic ileus.

Exhibits

Select words from the choices below to fill in each blank in the following sentence:

The findings in the client's medical record indicate
dropdown
and
dropdown
.