A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities?

An insurance agency offering a life insurance policy.

A family member who requests the client's diagnosis.

A physical therapist who is involved in the client's care.

An employer completing a pre-employment screening.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C: A physical therapist who is involved in the client's care.

Choice A rationale:

Disclosing health information to an insurance agency offering a life insurance policy typically requires the client's written permission due to the sensitive nature of the information being shared, including medical history and conditions.

Choice B rationale:

Revealing a client's diagnosis to a family member without written consent would violate the client's privacy rights. Health information is protected by privacy laws, and disclosure should only occur with the client's explicit permission.

Choice C rationale:

This is the correct entity to whom health information can be disclosed without the client's written permission. Health professionals who are actively involved in the client's care, such as a physical therapist, are considered part of the healthcare team and may need access to relevant health information for proper treatment.

Choice D rationale:

Disclosing health information to an employer completing a pre-employment screening generally requires the client's consent, as pre-employment screenings often involve sharing medical information that could impact the employment decision.

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Correct Answer is A

Explanation

The correct answer is Choice A - Measure the client's gastric residual before each feeding.

Choice A rationale:

The nurse's first action in caring for a client receiving intermittent enteral feedings should be to measure the client's gastric residual before each feeding. Gastric residual volume helps assess the client's tolerance to enteral feedings and can indicate delayed gastric emptying or potential complications like aspiration. If the residual volume is high, the nurse can collaborate with the healthcare team to determine whether to hold the feeding, adjust the feeding rate, or take other appropriate actions to ensure the client's safety and optimal nutritional status.

Choice B rationale:

Changing the enteral feeding bag and tubing every 24 hours is important to maintain the sterility and integrity of the feeding system. However, it is not the first action the nurse should take. The priority is to assess the client's tolerance to the feeding by measuring gastric residuals, which helps prevent complications.

Choice C rationale:

Documenting intake and output is a crucial aspect of nursing care for all clients, including those receiving enteral feedings. However, in the context of intermittent enteral feedings, measuring gastric residuals before each feeding is a more immediate and specific action to ensure the client's safety and well-being.

Choice D rationale:

Flushing the tubing with 30 mL of water after each feeding is important to prevent clogging and maintain the patency of the enteral feeding tube. However, this action is secondary to measuring gastric residuals, which directly assesses the client's tolerance to the feedings and helps prevent complications.

A. Use warm water when bathing the client. B. Place a donut-shaped cushion in the client's chair. C. Massage reddened areas over bony prominences. D. Maintain the client in high-Fowler's position.

Correct Answer is A

Explanation

The correct answer is choice A. Use warm water when bathing the client.

Choice A rationale:

Using warm water when bathing helps maintain skin integrity by ensuring the skin is clean without causing excessive dryness or irritation. Warm water is gentle on the skin and helps in maintaining its natural moisture balance.

Choice B rationale:

Placing a donut-shaped cushion in the client’s chair is not recommended as it can cause pressure points and restrict blood flow, potentially leading to pressure ulcers.

Choice C rationale:

Massaging reddened areas over bony prominences is not advisable because it can cause further damage to already compromised skin and increase the risk of pressure ulcers.

Choice D rationale:

Maintaining the client in high-Fowler’s position for extended periods can increase pressure on the sacral area, leading to pressure ulcers. It is important to regularly reposition the client to alleviate pressure.

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A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

Correct Answer is A

Explanation

A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Correct Answer is A

Explanation

A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend?

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

A nurse is preparing to administer medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching?

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?