A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

"Do you understand HIPAA regulations?"

"This discussion is only appropriate in a private area."

"Please stop this discussion."

"Did you know you can be liable if you breach confidentiality?"

Answer and Explanation

The Correct Answer is C

A. While understanding HIPAA regulations is important, addressing the immediate inappropriate behavior takes precedence.

B. While directing the conversation to a private area is appropriate, stopping the discussion immediately is the priority.

C. The priority is to stop the discussion immediately to prevent further breach of confidentiality.

D. While informing about potential liability for breaching confidentiality is important, addressing the immediate behavior is the priority.

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Free Nursing Study Resources

Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

A. To best hear the closing of the aortic heart valve, the nurse should place the diaphragm of the stethoscope at the second intercostal space, right sternal border. This is also known as the aortic area.
B. This is the tricuspid region, and defects with the tricuspid valve will be best heard in this area.
C. This is the mitral region and murmurs due to defects in the mitral valve will be appreciated here

A. Heart rate greater than 60/min B. Pedal pulses 2+ C. Pacer spikes after the QRS complex D. Distended jugular veins

Correct Answer is A

Explanation

- A: A heart rate greater than 60/min indicates that the transcutaneous pacing is effectively maintaining a heart rate within a normal range, which is crucial for adequate cardiac output and systemic perfusion.
- B: While 2+ pedal pulses indicate good peripheral perfusion, they do not directly reflect the effectiveness of transcutaneous pacing in treating complete heart block.
- C: Pacer spikes should appear before the QRS complex to show that the pacing stimulus is being delivered appropriately. Spikes after the QRS complex suggest that the pacing is not capturing the heart effectively.
- D: Distended jugular veins would be more indicative of heart failure or fluid overload and do not directly relate to the effectiveness of pacing therapy.

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A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?

Correct Answer is A

Explanation

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