Nokea
A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?
- A. I can only give medical information to the client with an approved interpreter.'
- B. The healthcare provider will share this information with you.'
- C. I'm sorry, but your sibling's medical information is none of your business.'
- D. I can give you those results as soon as I get them back from the lab.'
Correct Answer: A
Rationale: Approved interpreter ensures confidentiality.
You may also like to solve these questions
The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?
- A. Obtain permission from the nursing supervisor to transport the client without protective equipment.
- B. Place protective goggles over the client's eyeglasses after first positioning the face mask.
- C. Instruct the client about the need to wear a fitted respirator-style mask when leaving the room.
- D. Secure a surgical face mask over the bridge of the client's nose just below the eyeglasses.
Correct Answer: D
Rationale: Surgical mask ensures droplet precaution compliance.
While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: Notifying IT ensures prompt system resolution.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
- A. Stop suctioning until the pulse oximeter reading is above 95%.
- B. Reposition the pulse oximeter clip to obtain a new reading.
- C. Complete the intermittent suction of the nasopharynx.
- D. Apply an oxygen mask over the client's nose and mouth.
Correct Answer: B
Rationale: Repositioning ensures accurate saturation readings.
Which assessment is most important for the nurse to perform prior to the application of a heating pad?
- A. Muscle strength and tone.
- B. Presence of rebound phenomenon.
- C. Limitations to range of motion.
- D. Degree of neurosensory impairment.
Correct Answer: D
Rationale: Neurosensory impairment risks burns.
The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
- A. Leave the dressing off until consulting with the healthcare provider.
- B. Apply a hydrocolloidal gel dressing.
- C. Replace the gauze with a transparent dressing.
- D. Increase the frequency of the dressing changes.
Correct Answer: B
Rationale: Hydrocolloidal dressing promotes healing in granulating wounds.