Nokea
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 a medical interpreter service on behalf of a client
- B. To a family member when the client is not available
- C. To an employer for a pre-employment screening
- D. To an insurance agency in regard to a life insurance policy
Correct Answer: A
Rationale: Disclosure to an interpreter is permissible under HIPAA to facilitate care.
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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. Overweight
- B. Underweight
- C. Ideal body weight
- D. Obese
Correct Answer: A
Rationale: A BMI of 25-29.9 is categorized as 'overweight.' This indicates that the client is above the ideal weight range but has not reached the threshold for obesity.
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.
- A. Encourage the client to splint the abdomen when coughing.
- B. Administer acetaminophen.
- C. Administer ondansetron.
- D. Remind the client to use the incentive spirometer five times per hr.
- E. Encourage the client to cough and deep breathe.
- F. Plan to ambulate the client 30 min after the next analgesic is administered.
Correct Answer: A,D,E,F
Rationale: A: Splinting reduces pain during coughing. D: Incentive spirometry prevents atelectasis. E: Coughing and deep breathing clear secretions. F: Ambulation post-analgesic promotes lung expansion.
A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?
- A. Tell me your expectations about activities related to the end-of-life.
- B. You can provide the name of a spiritual support person we can contact for you.
- C. You can allow your family to visit as often as you wish.
- D. We can talk to the provider about incorporating nonpharmacological pain management in your care.
Correct Answer: A
Rationale: Asking about expectations establishes a foundation for personalized end-of-life care planning.
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Clasp their hands together in a relaxed position behind their body at their waist.
- B. Interlock their fingers and hold their hands away from their body above their waist.
- C. Keep their arms at the sides of their body with their hands in a relaxed position.
- D. Place one hand over the other against the part of the gown covering their upper body.
Correct Answer: B
Rationale: Interlocking fingers above the waist prevents glove contamination.
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.