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Which nursing actions are appropriate in this situation? Select all that apply.
- A. Notify housekeeping to come and dispose of the papers.
- B. Toss the papers in the trash.
- C. Put the papers into the shredder bin.
- D. Try to determine who left the papers unattended.
- E. State the papers neatly, placing them off to the side.
- F. Notify the office manager of the breach in confidentiality.
Correct Answer: C,F
Rationale: Unattended medical records are a breach of confidentiality under HIPAA. Shredding the papers ensures secure disposal, and notifying the office manager addresses the violation. Tossing in the trash or stacking neatly does not protect confidentiality, and housekeeping or identifying the culprit are not immediate priorities.
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Which action by the nurse is most appropriate?
- A. Allow the client's partner to stay in the examination room.
- B. Ask the client's friend to remain in the waiting room.
- C. Ask the physician to make the decision in this situation.
- D. Suggest that the friend wait outside the examination room door.
Correct Answer: A
Rationale: Allowing the client's partner to stay respects the client's preference and provides emotional support, as long as the client consents and privacy is maintained.
Which statement indicates further instruction is needed for the client with a cystocele?
- A. I need to have a sonogram to diagnose this problem.'
- B. I need to practice Kegel exercises to help strengthen my muscles.'
- C. I lose my urine when I sneeze because of my cystocele.'
- D. I can never have sexual intercourse again.'
Correct Answer: D
Rationale: Cystocele does not preclude sexual intercourse; this statement indicates a misconception needing correction. Sonograms aid diagnosis, Kegels are appropriate, and stress incontinence is a symptom.
If the lump has the following characteristics when the nurse palpates the breast tissue, which one is most suggestive that the lump may be a common?
- A. The lump can be easily moved about.
- B. The lump is about 1/2" (1 cm).
- C. The lump is irregularly shaped.
- D. The lump is near the areola.
Correct Answer: C
Rationale: Irregularly shaped lumps are more suggestive of malignancy, as benign lumps are typically smooth and mobile. Size, mobility, and location near the areola are less specific indicators.
When the nurse administers the parenteral form of the antineoplastic drug, which nursing action is best for preventing accidental self-absorption of the drug?
- A. Use only prefilled syringes.
- B. Wear disposable examination gloves.
- C. Dilute the drug with saline solution.
- D. Mix the drug in a closed vial.
Correct Answer: B
Rationale: Wearing gloves prevents skin contact with antineoplastic drugs, reducing the risk of absorption and toxicity.
Which intervention for applying antiembolism stockings is most appropriate to include in the client's care plan?
- A. Have the client wear the stockings continuously, but remove and reapply them at least twice a day.
- B. Have the client wear the stockings continuously during the day hours, and remove them at night.
- C. Have the client wear the stockings only when getting up to ambulate.
- D. Have the client wear the stockings only while in bed.
Correct Answer: A
Rationale: Removing and reapplying stockings twice daily ensures skin inspection and hygiene while maintaining continuous compression to prevent thrombosis.