A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?

A client who is receiving heparin and has an aPTT of 34 seconds (30 to 40 seconds).

A client who has type 1 diabetes mellitus and uses an insulin pump.

A client who has orthostatic hypotension and is receiving IV fluids,

A client who is at risk for pressure injuries and has an albumin level of 4.2 g/dL (3.5 to 5 g/dL).

None

Answer and Explanation

The Correct Answer is B

A. The client’s aPTT is within the therapeutic range for heparin, so immediate interdisciplinary discussion is not required.

B. Clients using insulin pumps require coordination between the nurse, endocrinologist, and diabetes educator to ensure safe insulin administration and blood glucose management, making an interdisciplinary conference appropriate.

C. Orthostatic hypotension being managed with IV fluids can typically be addressed within routine nursing care without needing an interdisciplinary meeting.

D. The client’s albumin level is within normal limits, and risk for pressure injuries can be managed with standard nursing interventions without requiring a conference.

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Correct Answer is A

Explanation

Choice A Reason:
The patient should be elevated 45-90° before inserting a nasogastric tube helps prevent aspiration and facilitates tube insertion.
Choice B Reason:
Assisting the client into a fetal position on his side in preparation for a lumbar puncture is a proper positioning technique to facilitate the procedure and minimize discomfort for the client.
Choice C Reason:
Assessing the client's gag reflex following an esophagogastroduodenoscopy (EGD) is standard practice to ensure the client's safety and ability to protect their airway after the procedure.
Choice D Reason:
Maintains the chest tube collection device below the level of the insertion site when ambulating the client is correct. Chest tube management is critical to prevent complications such as air leaks, tension pneumothorax, and tube dislodgement. When ambulating a client with a chest tube, it's essential to keep the collection device below the level of the insertion site to ensure proper drainage and prevent air from entering the pleural space. If the collection device is positioned above the insertion site, it could result in fluid or air backflow into the patient's chest cavity, which can lead to complications.

A. An assistive personnel is informing a friend of the client about their condition. B. A nurse and a provider are discussing a client's condition at the nurses' station while a visitor is present. C. An assistive personnel logs out of the computer prior to responding to a call light. D. A nurse is faxing data about a client to a preferred provider. E. A nurse is reviewing an electronic list of all clients admitted to the unit.

Correct Answer is ["A","B","E"]

Explanation

A.This is a clear breach of confidentiality as sharing client information with individuals who are not part of the healthcare team and without the client's consent violates patient privacy.

B.Discussing a client’s condition in a public area where unauthorized individuals (like visitors) can overhear is a breach of confidentiality. Patient information should be discussed in private settings to protect the client's privacy.

C.This action is a good practice to protect patient information and does not breach confidentiality.

D.This is acceptable as long as proper protocols are followed, such as using secure fax lines and confirming that the receiving party is authorized to receive the information. This action does not inherently breach confidentiality.

E.If the nurse is not involved in the care of all those clients and does not have a legitimate reason to access that information, this action can also be considered a breach of confidentiality. Healthcare providers should only access information relevant to their role and responsibilities.

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A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

Correct Answer is A

Explanation

A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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