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A nurse on a unit is assisting with the care of a group of clients. Which of the following observations by the nurse requires intervention?

A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for.

A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use.

A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care.

A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report.

Answer and Explanation

The Correct Answer is C

A. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: This is appropriate documentation practice. Nurses are responsible for documenting client information in the EMR when they provide direct care, ensuring accurate and timely records.

B. A nursing colleague printing material that does not contain identifiable information from a client's electronic medical record (EMR) for professional use: If no identifiable client information is included, and it is for professional, educational, or training purposes, this action is acceptable and does not violate confidentiality.

C. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care: Discussing confidential client information with staff not directly involved in the client's care is a violation of HIPAA and breaches client privacy. Only staff responsible for the client's care should access or discuss their health information.

D. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: This is appropriate because handoff reports ensure continuity of care. Discussing necessary client information with the next caregiver is essential for safe, effective client management.

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Correct Answer is B

Explanation

A. Amyloid plaque: Amyloid plaque buildup is characteristic of Alzheimer’s disease, a chronic, progressive form of dementia. While dementia can increase the overall risk for delirium, amyloid plaques themselves are not an immediate trigger for acute confusion like delirium.

B. Urinary tract infection: Urinary tract infections are a common reversible cause of delirium, especially in older adults. Infections can trigger a systemic inflammatory response and disrupt normal brain function, leading to sudden-onset confusion, disorientation, and restlessness due to systemic inflammation and changes in metabolic balance.

C. High cholesterol: High cholesterol contributes to long-term cardiovascular risks, such as atherosclerosis and stroke, but it is not directly linked to the sudden cognitive changes seen in delirium. It does not cause the acute neurological dysfunction characteristic of delirium.

D. Hypersomnia: Hypersomnia, or excessive daytime sleepiness, may reflect underlying sleep disorders or other chronic conditions, but it is not recognized as a common direct cause of delirium. Acute changes in mental status are more often tied to factors like infection, medications, or metabolic disturbances.

A. Weight B. Potassium C. Pedal pulses D. Temperature E. Orientation F. Chest x-ray G. Urine output

Correct Answer is ["A","C","F","G"]

Explanation

Weight: The client has gained over 1 kg (about 2.2 lb) within a week, suggesting fluid retention. In combination with crackles, edema, and cardiomegaly, this weight gain indicates worsening heart failure and requires prompt intervention to manage fluid overload.
Potassium: A potassium level of 3.5 mEq/L is at the lower limit of normal. While it should be monitored, it does not independently demand immediate action unless it trends lower or the client shows symptoms of hypokalemia.
Pedal pulses: Pedal pulses have decreased from 2+ to 1+, and the extremities are now cool. These changes suggest compromised peripheral circulation, likely related to decreased cardiac output, and warrant further assessment and management.
Temperature: The client’s temperature is within the normal range. There are no signs of fever or hypothermia, so this finding does not require immediate action based on the current clinical data.
Orientation: The client remains alert and oriented, with no noted decline in mental status. Therefore, orientation findings are stable and do not necessitate further immediate intervention.
Chest x-ray: The presence of cardiomegaly on chest x-ray suggests worsening heart failure or fluid overload. This finding is significant and requires timely medical evaluation and management to prevent further cardiac decompensation.
Urine output: The client’s urine output has drastically decreased from 520 mL/hr to 160 mL in 8 hours, indicating impaired renal perfusion or acute kidney injury. This is a critical finding and requires immediate provider notification and intervention.

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A nurse on a unit is assisting with the care of a group of clients. Which of the following observations by the nurse requires intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client. A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

Correct Answer is ["A","C","F","G"]

Explanation

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A nurse is assisting with the care of a client in a medical-surgical unit. Which of the following actions should the nurse take to decrease the risks for a urinary tract infection for this client? Select all that apply.

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