Nokea
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Respiratory therapist
- B. Speech-language pathologist
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: B
Rationale: Speech-language pathologists specialize in dysphagia, assessing and treating swallowing issues post-stroke.
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A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Complete an incident report about the breach of confidentiality.
- B. Tell the nurse that permission from the risk manager is required to view the client's record.
- C. Remind the nurse that only staff caring for the client may access the client's record.
- D. Contact facility security to remove the nurse from the unit.
Correct Answer: C
Rationale: Reminding about access protocol directly addresses unauthorized viewing, maintaining confidentiality per HIPAA.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Secure the restraints with a square knot.
- B. Check the client's range of motion every 6 hr.
- C. Make sure two fingers fit under the restraints.
- D. Request a prescription renewal from the provider every 36 hr.
Correct Answer: C
Rationale: Ensuring two fingers fit prevents excessive tightness, promoting circulation and safety.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Removing the client's dentures from their mouth
- B. Washing the client's face
- C. Closing the client's eyes
- D. Gathering the client's personal belongings
Correct Answer: A
Rationale: Removing dentures is a nursing task to ensure proper handling, requiring intervention.
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To a family member when the client is not available
- B. To an employer for a pre-employment screening
- C. To an insurance agency in regard to a life insurance policy
- D. To a medical interpreter service on behalf of a client
Correct Answer: D
Rationale: Disclosure to an interpreter facilitates care and is permitted under HIPAA without consent.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Apply clean gloves.
- C. Prick the side of the client's finger.
- D. Elevate the client's hand above the level of the heart.
- E. Cleanse the client's finger with an iodine swab.
Correct Answer: B,C,E
Rationale: B: Gloves ensure infection control. C: Side prick is correct technique. E: Iodine disinfects; A risks hemolysis, D impedes flow.