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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.
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Nurses' Notes
Day 1:
The client is receiving intermittent tube feedings via a nasogastric tube.
Abdomen is soft, nondistended.
Head of client's bed is positioned to 30° pH of gastric aspirate 4.0
Gastric residual volume is 50 mL Day 2:
Abdomen is distended. Client reports nausea and is coughing.
Gastric residual volume 550 mL pH of gastric aspirate 4.5
Nurses' Notes
Day 2:
Abdomen is distended. Client reports nausea and is coughing Gastric residual volume 550 mL
pH of gastric aspirate 4.5 Vital Signs
Day 2:
Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min
Pulse oximetry 90% on room air
Select the findings in the client's medical record that require further action by the nurse. To deselect a finding, click on the finding again.
Choices
Nurses' Notes Day 2:
Abdomen is distended. Client reports nausea and is coughing
Gastric residual volume 550 mL pH of gastric aspirate 4.5
Vital Signs
Day 2:
Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min
Pulse oximetry 90% on room air
A. Distended abdomen
B. Reports nausea and coughing
C. Gastric residual volume
D. Heart rate 110/min
E. Respiratory rate 24/min
F. pH of gastric aspirate 4.5
G. Temperature 37° C (98.6° F)
A nurse is assisting in the care of a client. Select the findings in the client's medical record that require further action by the nurse.
- A. Distended abdomen
- B. Reports nausea and coughing
- C. Gastric residual volume 550 mL
- D. Heart rate 110/min
- E. Respiratory rate 24/min
- F. pH of gastric aspirate 4.5
- G. Temperature 37° C (98.6° F)
Correct Answer: A,B,C,D,E
Rationale:
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Limit snacks between meals.
- B. Provide the client with finger foods for meals.
- C. Restrict visitors during meals.
- D. Provide the client with three large meals each day.
Correct Answer: B
Rationale: Finger foods simplify eating for dementia patients, encouraging intake despite utensil challenges.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Notify the provider of the client's refusal.
- B. Document the refusal in the client's medical record.
- C. Inform the client of the potential consequences of their refusal.
- D. Return the medication to the medication cabinet.
Correct Answer: C
Rationale: Informing about consequences first educates the client, supporting informed decision-making.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 25 kg × 50 mg/kg/day = 1250 mg/day; 1250 mg ÷ 4 = 312.5 mg/dose; 312.5 mg ÷ (125 mg/5 mL) = 12.5 mL.
A nurse is caring for a client who is postoperative.
Medication Administration Record
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
What documentation in the client's medical record requires further action by the nurse.
- A. Temperature 37.5° C (99.5° F)
- B. Client is difficult to arouse.
- C. Respiratory rate 10/min
- D. Pulse oximetry 88% on room air
- E. Pupils are 3 mm, equal, and reactive to light. Blood pressure 99/46 mm Hg
- F. Heart rate 61/min
Correct Answer: B,C,D
Rationale: