Nokea
The nurse overhears a surgical team member discussing a client's procedure in the hospital cafeteria. The nurse should:
- A. Report the breach to the hospital's privacy officer.
- B. Confront the team member immediately.
- C. Document the incident in the client's chart.
- D. Ignore the conversation as it was unintentional.
Correct Answer: A
Rationale: Discussing client information in a public area violates HIPAA. Reporting to the privacy officer ensures proper handling of the confidentiality breach.
You may also like to solve these questions
The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.
- A. The client has a sore throat.
- B. The client appears drowsy following the procedure.
- C. The client has epigastric pain.
- D. The client experiences hematemesis.
Correct Answer: C,D
Rationale: Epigastric pain and hematemesis after a gastroscopy may indicate complications such as perforation or bleeding. A sore throat and drowsiness are expected post-procedure effects due to throat irritation and sedation.
Which intervention is contraindicated for a client with a seizure disorder?
- A. Provide a safe environment.
- B. Use a padded tongue depressor.
- C. Administer prescribed anticonvulsants.
- D. Monitor post-seizure status.
Correct Answer: B
Rationale: Using a padded tongue depressor is contraindicated as it can cause injury during a seizure.
When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs?
- A. Nasogastric drainage.
- B. Urinary catheter.
- C. Dressing.
- D. Need for pain medication.
Correct Answer: C
Rationale: After a splenectomy, the nurse should assess the dressing for signs of bleeding, as the spleen is highly vascular, and postoperative hemorrhage is a risk. Nasogastric drainage, urinary output, and pain are assessed later, but the dressing is the priority to detect complications.
In which of the following clients is an autotransfusion contraindicated?
- A. The client who has cancer.
- B. The client who is in danger of cardiac arrest.
- C. The client with a contaminated wound.
- D. The client with a ruptured bowel.
Correct Answer: A,C,D
Rationale: Autotransfusion is contraindicated in cancer (risk of spreading malignant cells), contaminated wounds, or ruptured bowel (risk of infection or bacterial spread). It may be used cautiously in cardiac arrest if no other contraindications exist.
A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply.
- A. Administers long-acting or sustained-release oral pain formula (OxyContin) regularly around-the-clock.
- B. Administers immediate-release medication (oxycodone) for breakthrough pain.
- C. Avoids long-acting opioids due to her concern about addiction.
- D. Uses music for distraction as well as heat or cold in combination with medications.
- E. Substitutes acetaminophen (Tylenol) to avoid tolerance to the medications.
- F. Has her husband use a pain rating scale to measure the effectiveness at reaching his individual pain goal.
Correct Answer: A,B,D,F
Rationale: Effective pain management includes around-the-clock long-acting opioids (A), immediate-release opioids for breakthrough pain (B), non-pharmacologic methods like music or heat/cold (D), and using a pain scale to assess effectiveness (F). Avoiding long-acting opioids (C) or substituting acetaminophen (E) is not appropriate for severe cancer pain.