A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

Tell the APS to stop the conversation.

Document the event in the client's progress notes.

Inform the client of the AP's actions.

Submit an incident report to the risk manager.

Answer and Explanation

The Correct Answer is A

Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.

When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.

The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.

The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.

Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.

A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client

A. Temperature 38.8° C (101.8° F) B. Straw-colored urine C. Apical pulse rate 58/min D. Blood pressure 158/92 mm Hg

Correct Answer is A

Explanation

The correct answer is: a. Temperature 38.8° C (101.8° F)

Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.

Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.

Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.

Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?

Correct Answer is A

Explanation

A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family?

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

A nurse is collecting data from a client who is at 20 weeks of gestation and has been taking ferrous sulfate. For which of the following findings should the nurse monitor as a common adverse effect of iron supplementation and report to the provider?

A nurse is reinforcing teaching with a client about collecting a stool specimen to check for occult blood. Which of the following statements by the client indicates an understanding of the teaching?

A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?

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