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A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?
- A. The ethics committee will need to approve this request for you.
- B. I will ask the nursing supervisor to obtain the medical records for you.
- C. The healthcare provider will share this information with you.
- D. The client must provide permission to share the records with you.
Correct Answer: D
Rationale: The correct response is D: The client must provide permission to share the records with you. This is the correct answer because under HIPAA regulations, a client's medical records are confidential and can only be shared with the client's explicit permission. The nurse cannot disclose the records to a family member without the client's consent. Option A is incorrect because the ethics committee does not handle individual requests for medical records. Option B is incorrect as the nursing supervisor cannot release medical records without proper authorization. Option C is incorrect as the healthcare provider cannot share the information without the client's consent.
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A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
- A. A client who has Guillain-Barré syndrome
- B. A client who has systemic sclerosis
- C. A client who has amyotrophic lateral sclerosis (ALS)
- D. A client who has a lumbosacral spinal tumor
Correct Answer: D
Rationale: The correct answer is D: a client who has a lumbosacral spinal tumor. This client may require meal assistance due to potential physical limitations caused by the tumor. The nurse should delegate this task to the AP because it falls within their scope of practice.
Choice A (Guillain-Barré syndrome), Choice B (systemic sclerosis), and Choice C (ALS) all involve neuromuscular conditions that can affect the client's ability to swallow or chew, and thus meal assistance should be provided by a higher-level healthcare provider.
In summary, the correct answer is D because the client with a lumbosacral spinal tumor is more likely to need assistance with meals due to physical limitations, and the AP is appropriate for this task. The other choices involve conditions where meal assistance may require more specialized care.
A nurse is preparing to turn a client who is obese following a spinal fusion. The nurse should plan to use which of the following techniques to turn this client?
- A. Draw sheet
- B. Log roll
- C. Sliding board
- D. Hoyer lift
Correct Answer: B
Rationale: The correct answer is B: Log roll. When turning an obese client following spinal fusion, using a log roll technique is most appropriate. This technique involves turning the client as a single unit to prevent twisting or bending of the spine, reducing the risk of injury. The nurse should assist the client by coordinating the movement with other staff members to ensure a smooth and safe transition. The other choices are not suitable for this scenario: A) Draw sheet is typically used for moving a client up in bed, not for turning an obese client after spinal fusion. C) Sliding board is used for transferring clients from one surface to another, not for turning in bed. D) Hoyer lift is used for lifting and transferring clients who are unable to bear weight, not for turning a client in bed.
A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?
- A. Leave the pad in place for at least 40 minutes
- B. Set the pad’s temperature to 42.2°C (108°F)
- C. Use safety pins to keep the pad in place
- D. Stop the treatment if the client’s skin becomes red
Correct Answer: D
Rationale: The correct answer is D: Stop the treatment if the client’s skin becomes red. This is important because redness indicates potential skin damage or burns due to excessive heat exposure. It is crucial to monitor the client's skin during heat application to prevent harm. Choice A is incorrect because leaving the pad in place for a specific duration can lead to skin damage if the temperature is too high. Choice B is incorrect as setting the pad's temperature too high can cause burns. Choice C is incorrect as safety pins can cause injury or discomfort to the client. Therefore, the correct action is to closely monitor the client's skin for any signs of redness and stop the treatment immediately if redness occurs to prevent further harm.
A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
- A. Use wool blankets on your bed.
- B. Do not adjust the oxygen flow rate.
- C. Store unused oxygen tanks horizontally.
- D. Check your oxygen equipment once each week.
Correct Answer: B
Rationale: The correct answer is B: Do not adjust the oxygen flow rate. It is essential not to adjust the oxygen flow rate as it is prescribed by a healthcare provider based on the client's condition. Incorrectly adjusting the flow rate can lead to inadequate oxygen delivery or oxygen toxicity. Choice A is incorrect as wool blankets can generate static electricity, which can be dangerous around oxygen. Choice C is incorrect because oxygen tanks should be stored vertically to prevent accidents. Choice D is incorrect as oxygen equipment should be checked daily for safety and functionality.
A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?
- A. Apply bilateral wrist restraints.
- B. Administer opioids for pain.
- C. Implement a soft diet.
- D. Offer fluids through a straw.
Correct Answer: C
Rationale: Correct Answer: C. Implement a soft diet.
Rationale: A soft diet is appropriate post-cleft palate repair to minimize trauma to the surgical site and promote healing. It helps prevent injury and discomfort to the surgical area, allowing for adequate nutrition without causing harm.
Incorrect Choices:
A: Applying bilateral wrist restraints is unnecessary and could potentially harm the toddler, leading to increased agitation and discomfort.
B: Administering opioids for pain may not be necessary for a toddler post-cleft palate repair unless there are specific indications for severe pain.
D: Offering fluids through a straw can increase the risk of aspiration and compromise the surgical site's healing process. It is not recommended post-cleft palate repair.