A nurse is assisting in the care of a client.

Exhibits

Complete the following sentence by using the lists of options.

At 1000 the nurse enters the client's room. The first action the nurse should take is
dropdown
followed by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for Correct Answers:

Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.

Nursing Test Bank

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Correct Answer is B

Explanation

A. "My doctor will choose which medical procedures I will have." A living will allows the client to specify their own wishes regarding medical treatment, rather than leaving decisions solely to the doctor. It is a legal document that guides providers based on the client’s preferences.

B. "I can revise my living will if I change my mind." Clients have the right to update or revoke their living will at any time, reflecting changes in their preferences or health status. This flexibility is an important aspect of advance directives and indicates understanding.

C. "My family can change the decisions in my living will." The family cannot override the client’s living will unless legally appointed as a healthcare proxy. The living will represents the client’s autonomous decisions and must be honored by healthcare providers.

D. "I need an attorney to write my living will." While legal advice can be helpful, clients do not need an attorney to create a living will. Many states provide standardized forms that individuals can complete without legal assistance.

A. Gather additional information from the caller to verify their identity. B. Request that the caller contact the client's provider directly for information. C. Ask the caller to contact the client directly for information. D. Provide the caller with a brief update about the client's condition.

Correct Answer is C

Explanation

A. Gather additional information from the caller to verify their identity: Even if the caller's identity is verified, HIPAA regulations prohibit disclosing a client's medical information without the client’s explicit authorization. Verifying identity alone does not grant permission to release confidential health information.

B. Request that the caller contact the client's provider directly for information: Redirecting the caller to the provider does not resolve the issue of confidentiality. Healthcare providers are also bound by HIPAA regulations and cannot release information without proper consent, regardless of who is making the request.

C. Ask the caller to contact the client directly for information: This action respects the client’s privacy and autonomy. Under HIPAA, healthcare professionals may not disclose health information without client authorization. Advising the sibling to speak directly with the client is the appropriate response to safeguard confidentiality.

D. Provide the caller with a brief update about the client's condition: Sharing any health information without the client’s express consent is a violation of HIPAA. Even a brief update constitutes a breach of confidentiality and could result in legal and professional consequences.

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A nurse is assisting in the care of a client. Exhibits Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is dropdown followed by dropdown .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is planning to complete a living will. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse in a provider's office receives a telephone call from a client's sibling requesting current information about the client's condition. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?

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A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?

A nurse is assisting in the care of a client.

Exhibits

Complete the following sentence by using the lists of options.

At 1000 the nurse enters the client's room. The first action the nurse should take is
dropdown
followed by
dropdown
.