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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. Contact facility security to remove the nurse from the unit.
- B. Complete an incident report about the breach of confidentiality.
- C. Remind the nurse that only staff caring for the client may access the client's record.
- D. Tell the nurse that permission from the risk manager is required to view the client's record.
Correct Answer: C
Rationale: Reminding the nurse about confidentiality reinforces HIPAA compliance without escalating unnecessarily.
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A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: B
Rationale: Poorly fitting dentures impair nutrition, a priority health risk requiring immediate attention.
A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Obese
- B. Underweight
- C. Ideal body weight
- D. Overweight
Correct Answer: D
Rationale: A BMI of 25-29.9 is classified as overweight; 30+ is obese.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. You need to talk with your doctor about this.
- B. Not receiving blood will slow down your recovery.
- C. I understand that you decided not to receive blood products.
- D. Why are you refusing to receive blood products?
Correct Answer: C
Rationale: Acknowledging the refusal respects autonomy while opening dialogue.
A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?
- A. The device requires the client to use upper body strength.
- B. The sides of the sling are for the client to hold on to.
- C. The lower end of the sling goes below the client's calves.
- D. This type of device is useful for a client who cannot assist.
Correct Answer: D
Rationale: A mechanical lift is designed for clients unable to assist, ensuring safe transfer.
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. Assess the pain level of a client who has received acetaminophen.
- B. Measure the intake and output of a client who has received furosemide.
- C. Check a client's peripheral IV site for redness or swelling.
- D. Reinforce teaching with a client about crutch-gait walking.
Correct Answer: B
Rationale: Measuring intake and output is within the AP's scope; assessment and teaching are nurse responsibilities.