Nokea
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. Contact facility security to remove the nurse from the unit.
- C. Complete an incident report about the breach of confidentiality.
- D. Remind the nurse that only staff caring for the client may access the client's record.
Correct Answer: D
Rationale: This action reinforces HIPAA compliance without escalating unnecessarily.
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A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Hyperthermia
- B. Urticaria
- C. Dyspnea
- D. Headache
Correct Answer: C
Rationale: Dyspnea is a critical sign of a transfusion reaction, requiring immediate reporting.
A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?
- A. I will rinse the contaminants from a bedpan with hot water.
- B. I will wear sterile gloves when bathing a client who is incontinent.
- C. I will use disinfectant to clean the blood pressure cuff after use on a client.
- D. I will double-bag a client's linens each day.
Correct Answer: C
Rationale: Disinfecting equipment like a BP cuff prevents cross-contamination between clients.
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 an employer for a pre-employment screening
- B. To an insurance agency in regard to a life insurance policy
- C. To a family member when the client is not available
- D. To a medical interpreter service on behalf of a client
Correct Answer: D
Rationale: Disclosure to an interpreter is permitted under HIPAA to facilitate care.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. Unnecessary sterile items are placed on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle.
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. Using clean gloves
Correct Answer: B, E
Rationale: B: Pricking the side avoids painful areas. E: Clean gloves ensure infection control.