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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. Tell the nurse that permission from the risk manager is required to view the client's record.
- B. Remind the nurse that only staff caring for the client may access the client's record.
- C. Complete an incident report about the breach of confidentiality.
- D. Contact facility security to remove the nurse from the unit.
Correct Answer: B
Rationale: Reminding about access rules upholds confidentiality standards.
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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. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart.
- D. Cleanse the client's finger with an iodine swab.
- E. Apply clean gloves.
Correct Answer: B,E
Rationale: B: Pricking the side is less painful and safer. E: Gloves prevent contamination and ensure safety.
A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Measure the intake and output of a client who has received furosemide.
- B. Assess the pain level of a client who has received acetaminophen.
- C. Reinforce teaching with a client about crutch-gait walking.
- D. Check a client's peripheral IV site for redness or swelling.
Correct Answer: A
Rationale: Measuring intake and output is within the AP’s scope and appropriate for delegation.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Scrub the inside and outside of the inner cannula with a small brush.
- B. Wipe the inside of the inner cannula with a folded pipe cleaner.
- C. Cleanse the stoma site with 0.9% sodium chloride solution.
- D. Unlock and remove the inner cannula.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: E,D,A,B,C
Rationale: E: Prepare solution. D: Remove cannula. A: Scrub cannula. B: Wipe cannula. C: Cleanse stoma maintains sterility.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. A family member will need to witness my signature on my living will.
- B. I need to create advance directives so that I can donate my organs.
- C. I can name my sibling as my designee in my durable power of attorney for health care.
- D. My advance directives can be enforced once my attorney approves them.
Correct Answer: C
Rationale: Naming a sibling as a designee in a durable power of attorney reflects understanding of advance directives.
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?
- A. I'll use focused breathing to control my pain.
- B. I'll learn to notice the sensation of muscle tension.
- C. I think about my grandfather's farm to reduce pain.
- D. I listen to my favorite music to take my mind off the pain.
Correct Answer: C
Rationale: Guided imagery involves visualizing a calming scene like a farm to distract from pain.