A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching?

"Change-of-shift report can be given at the client's bedside.”

"I can provide client information over the phone if the caller identifies themselves as family.”

"A client cannot see their medical record because it is considered to be property of the facility.”

"Access to client information is limited to direct care providers.”

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Giving change-of-shift report at the client's bedside is not appropriate due to privacy concerns. The client's room is not a private area for discussing their medical information, and other clients or visitors might overhear sensitive details. A more appropriate location, such as a designated nursing station, should be used for shift handoffs.

Choice B rationale:

Providing client information over the phone to callers identifying themselves as family is incorrect. Even if the caller identifies as family, the nurse cannot verify their identity over the phone. Sharing confidential client information without proper verification violates confidentiality policies and can compromise the client's privacy.

Choice C rationale:

Stating that the client cannot see their medical record because it is considered property of the facility is incorrect. Clients have the legal right to access their medical records under the Health Insurance Portability and Accountability Act (HIPAA). While the physical record might be owned by the facility, clients have the right to review their medical information.

Choice D rationale:

Access to client information is limited to direct care providers is the correct statement. Confidentiality requirements dictate that only authorized individuals involved in the client's care, treatment, or payment processes have access to their medical information. This helps protect the client's privacy and ensures that sensitive information is not disclosed to unauthorized parties.

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Correct Answer is D

Explanation

The correct answer is choice D.

Choice A rationale:

“Auscultate the client’s bowel sounds.” While auscultating bowel sounds can provide information about the client’s gastrointestinal function, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.

Choice B rationale:

“Measure the client’s temperature.” Measuring the client’s temperature can help identify if the client has an infection, which could be causing the vomiting and diarrhea. However, it is not the priority assessment in this situation.

Choice C rationale:

“Check the client’s urine specific gravity.” Checking the client’s urine specific gravity can provide information about the client’s hydration status. However, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.

Choice D rationale:

“Obtain the client’s serum potassium level.” This is the correct answer. Prolonged vomiting and diarrhea can lead to significant loss of electrolytes, including potassium. A low potassium level (hypokalemia) can have serious effects, including cardiac arrhythmias. Therefore, obtaining the client’s serum potassium level is the priority assessment.

A. Show the AP how to remove an indwelling urinary catheter. B. Review the AP's skill competency checklist. C. Ask the AP if they know how to remove an indwelling urinary catheter. D. Pair the newly hired AP with an experienced AP.

Correct Answer is B

Explanation

Choice A rationale:

Showing the AP how to remove an indwelling urinary catheter may not provide sufficient evidence of their competency to perform the task safely and effectively. This approach assumes that observation alone is enough to determine competence, which is not necessarily the case. It's important to have a more structured assessment of the AP's skills.

Choice B rationale:

Reviewing the AP's skill competency checklist is the most appropriate action to ensure the AP is qualified to remove the indwelling urinary catheter. Competency checklists outline specific skills and steps required for a task, and they serve as a standardized way to assess the AP's capabilities. This process ensures that the AP has received proper training and has demonstrated competence before performing the procedure independently.

Choice C rationale:

Simply asking the AP if they know how to remove an indwelling urinary catheter is not a comprehensive method for verifying their qualifications. Self-assessment can be unreliable and may not accurately reflect the AP's actual skill level. Relying solely on self-reporting could compromise patient safety and quality of care.

Choice D rationale:

Pairing the newly hired AP with an experienced AP might provide some guidance, but it doesn't systematically assess the individual's competence. The level of experience of the experienced AP may vary, and their ability to teach or evaluate the new AP's skills may not be standardized.

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A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports vomiting and diarrhea for the past 6 hours. The nurse should identify that which of the following assessments is the priority?

Correct Answer is D

Explanation

A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

Correct Answer is B

Explanation

A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need?

A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?

A nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, which of the following actions should the nurse manager take first?

A nurse is planning the discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn?

A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

A charge nurse is observing a newly licensed nurse's use of time-management skills. Which of the following actions by the newly licensed nurse indicates effective use of this skill?

A nurse is caring for a client who is terminally ill and receiving nutritional support. The client's adult children disagree about continuing nutritional support. The dilemma is referred to the ethics committee. Which of the following actions should the nurse expect the committee to take?

A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?