A nurse is caring for a postoperative male client in the surgical unit. The following exhibits are available for review

Exhibits

Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect documentation, click on the documentation again. Select all that apply

Respiratory rate 10/min

Pulse oximetry 88% on room air

Blood pressure 99/46 mm Hg

Morphine 10 mg administered subcutaneously

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale: The client’s respiratory rate of 10/min is below the normal range (12-20 breaths per minute). This suggests respiratory depression, which can be caused by opioid medications like morphine.

Choice B rationale: The client’s pulse oximetry reading of 88% on room air is lower than the normal range (95%-100%). This indicates hypoxemia, which may be due to respiratory depression from the morphine.

Choice C rationale: Although the blood pressure of 99/46 mm Hg is low, it might be acceptable for this client postoperatively. However, it does not require immediate intervention compared to the other choices.

Choice D rationale: The administration of morphine 10 mg subcutaneously needs further action because the client is showing signs of opioid overdose (e.g., respiratory depression, hypoxemia). This necessitates reassessment and potential adjustment of the medication dosage or frequency.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale

Health information should not be disclosed to an employer for pre-employment screening without the client's consent, as it violates privacy regulations and the client's right to confidentiality. Such disclosures could lead to discrimination or bias in employment decisions.

Choice B rationale

Disclosing health information to a family member without the client's consent is a breach of confidentiality. The client must provide explicit permission, unless the situation involves an immediate risk to the client's or others' safety, which is not indicated here.

Choice C rationale

Sharing health information with a medical interpreter service on behalf of a client is permissible, as it facilitates communication between the client and healthcare providers. This action supports the client's care and ensures accurate understanding of medical information, making it an exception to the confidentiality rule.

Choice D rationale

Disclosing health information to an insurance agency regarding a life insurance policy requires the client's consent. It involves sharing sensitive information that could affect policy terms and premiums. Without consent, this disclosure would breach confidentiality laws.

A. Clean the hearing aid with isopropyl alcohol. B. Turn the hearing aid off for 5 minutes. C. Soak the hearing aid in warm water. D. Decrease the volume on the hearing aid.

Correct Answer is D

Explanation

Choice A rationale

Cleaning the hearing aid with isopropyl alcohol is inappropriate as it can damage the device. Hearing aids should be cleaned with a dry, soft cloth or a brush specifically designed for this purpose to maintain their functionality.

Choice B rationale

Turning the hearing aid off for 5 minutes does not address the underlying cause of the whistling sound, which is often due to feedback or improper fit. Proper troubleshooting and adjustment are necessary to resolve the issue.

Choice C rationale

Soaking the hearing aid in warm water is incorrect and can severely damage the electronic components of the device. Hearing aids must be kept dry and handled according to the manufacturer's instructions.

Choice D rationale

Decreasing the volume on the hearing aid can reduce or eliminate the whistling sound caused by feedback. Adjusting the volume or repositioning the device can help achieve optimal functionality without causing discomfort or distortion. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality.In which of the following situations can the nurse disclose health information without the client's written consent?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who has a hearing aid.Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Correct Answer is D

Explanation

A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago.Which of the following actions should the nurse take?

A nurse is reviewing the laboratory reports of four clients.Which of the following clients should the nurse expect to have a positive fecal occult blood test?

A nurse is observing an assistive personnel (AP) apply a belt restraint to a client.Which of the following actions by the AP requires intervention by the nurse?

A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer.The employer asks the nurse about the client's condition.Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder.As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles.”. Which of the following actions should the nurse take?

A nurse is preparing to clean a blood spill on a bedside table.Which of the following solutions should the nurse plan to use?

A nurse is reinforcing teaching with a client who is perimenopausal.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is dying.One of the client's family members tells the nurse, "I need to help.What can I do?" Which of the following actions should the nurse take?