Nokea
The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?
- A. Describing a client's illness in the breakroom without mentioning a name.
- B. Discussing health history with the client behind a closed curtain.
- C. Faxing health records to the client's primary healthcare provider.
- D. Sharing a client's discharge needs with other treatment team members.
Correct Answer: A
Rationale: Public discussion risks confidentiality breach.
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The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?
- A. Fibromyalgia
- B. Peptic ulcer disease.
- C. Hypertension
- D. Hypothyroidism.
Correct Answer: C
Rationale: OSA increases blood pressure via hypoxia.
A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement?
- A. Orient the client to their surroundings.
- B. Close the client's room door.
- C. Escort the client back to the room.
- D. Raise the four side rails on the bed.
- E. Secure a bed alarm on the mattress.
Correct Answer: A,C,E
Rationale: Orientation, escort, and alarm ensure safety.
The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?
- A. Drink 800 to 1,000 milliliters of fluid daily.
- B. Take oxycodone as scheduled to prevent painful bowel movements.
- C. Add fat-containing foods in the diet to lubricate stools for easier passage.
- D. Ambulate early and as frequently as possible.
Correct Answer: D
Rationale: Ambulation stimulates bowel function.
The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?
- A. Complete an admission assessment.
- B. Access a central venous line.
- C. Reinforce discharge teaching.
- D. Initiate blood product infusions.
Correct Answer: C
Rationale: PNs can reinforce teaching within scope.
To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?
- A. Reduce the amount of pressure being applied on the top of the foot.
- B. Document in the nurse's notes that the dorsalis pedis pulse is not palpable.
- C. Obtain a Doppler stethoscope to auscultate the pulse at the same site.
- D. Palpate the site on the inner side of the ankle below the medial malleolus.
Correct Answer: C
Rationale: Doppler detects weak pulses.