A nurse is caring for a client who has cancer the client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make?

“I will ask your mother’s primary care provider to speak with you.”

“You will have to speak directly to your mother about her treatment.”

“What would you like to know about your mother’s treatment.”

“I cannot provide this information to you without your mother’s consent.”

Answer and Explanation

The Correct Answer is D

a. "I will ask your mother's primary care provider to speak with you."This response does not address the issue of confidentiality and consent. The nurse should not assume that the provider will discuss the treatment without the client's consent.

B. “You will have to speak directly to your mother about her treatment.” This response correctly redirects the child to the client but does not fully explain the importance of consent and confidentiality, which are crucial in maintaining professional and ethical standards.

C. “What would you like to know about your mother’s treatment.”This response might imply a willingness to share information without the client’s consent, which would be a violation of confidentiality and privacy laws.

D. “I cannot provide this information to you without your mother’s consent.” Correct. This response clearly states the need for the client’s consent before any information can be shared, adhering to the principles of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) regulations.

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Correct Answer is B

Explanation

a. A client who has just returned from the PACU:

Vital signs for a client who has just returned from the Post-Anesthesia Care Unit (PACU) are usually obtained by licensed nursing staff due to the potential for complications and the need for close monitoring.

b. A client who has a blood pressure of 110/68 mm Hg:

This client has stable vital signs, and obtaining blood pressure measurements within normal range is a routine task suitable for delegation to assistive personnel.

c. A client who is experiencing chest pain:

Clients experiencing chest pain require immediate assessment by licensed nursing staff or a healthcare provider. This is not a task appropriate for delegation to assistive personnel.

d. A client who has a fasting blood glucose of 104 mg/dL:

Monitoring blood glucose levels is typically within the scope of licensed nursing staff. Delegating tasks related to clients with diabetes or glucose monitoring to assistive personnel may not be appropriate.

A. Providing a 10 min rest period prior to meals B. Elevating the head of the client’s bed to 30 degrees during mealtime C. Instructing the client to place her chin toward her chest when swallowing D. Withholding fluids until the end of the meal

Correct Answer is C

Explanation

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

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A nurse is caring for a client who has cancer the client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to delegate tasks to an assistive personnel after receiving change-of-shift report. The nurse should assign the AP to obtain vital signs from which of the following clients?

Correct Answer is B

Explanation

A nurse is supervising an assistive personnel who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Correct Answer is C

Explanation

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