A nurse is teaching a newly licensed nurse about maintaining confidentiality within the nurse-client relationship. The nurse should include that which of the following situations warrants reporting confidential information?

When the client has a cognitive disorder

When the client's hospitalization is involuntary

When a member of the client's immediate family requests information

When the client has communicated an intention to harm someone

Answer and Explanation

The Correct Answer is D

A. When the client has a cognitive disorder: A cognitive disorder does not automatically remove a client’s right to confidentiality. Information should still be protected unless the client has a legal guardian or specific exceptions apply.

B. When the client's hospitalization is involuntary: Even in involuntary admissions, the client retains rights to confidentiality. Disclosure requires consent unless there is a risk of harm to self or others.

C. When a member of the client's immediate family requests information: Confidentiality must be maintained unless the client provides explicit permission for the information to be shared with family.

D. When the client has communicated an intention to harm someone: This is an exception to confidentiality. The nurse has a legal and ethical duty to report threats of harm to protect potential victims (duty to warn).

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Correct Answer is ["A","B","C","F","G"]

Explanation

A. Assist the client to the left lateral position: Repositioning improves uteroplacental perfusion, especially in the presence of variable decelerations. The left lateral position relieves pressure on the inferior vena cava, promoting fetal oxygenation.

B. Administer oxygen at 10 L/min via nonrebreather face mask: Oxygen is indicated to improve fetal oxygenation during nonreassuring FHR patterns like recurrent variable decelerations and minimal variability, both of which are present in this scenario.

C. Notify the provider of the client's condition: The combination of recurrent variable decelerations, minimal variability, and a history of meconium-stained fluid warrants immediate provider notification to assess further interventions and potential fetal compromise.

D. Request a prescription for oxytocin: Oxytocin stimulates uterine contractions and may worsen fetal distress in the presence of variable decelerations or minimal variability. It is contraindicated until the fetal status is stabilized.

E. Request a prescription for hydralazine: Hydralazine is used to treat hypertension. The client’s blood pressure is within normal range and does not require antihypertensive management at this time.

F. Prepare to administer an amnioinfusion: Amnioinfusion is indicated to dilute meconium-stained amniotic fluid and relieve cord compression, both of which are suggested by the variable decelerations and green-stained fluid earlier.

G. Initiate a bolus of IV fluid: IV fluid bolus improves maternal blood volume and uteroplacental perfusion, which can help resolve variable decelerations and increase fetal oxygenation during nonreassuring FHR patterns.

A. Strain the client's urine. B. Instruct visitors to stay 1 m (3.3 feet) away from the client. C. Attach a dosimeter to the client's gown. D. Limit each of the client's visitors to 2 hr per day.

Correct Answer is B

Explanation

A. Strain the client's urine: Straining urine is not necessary with low-dose rate brachytherapy for prostate cancer. The radioactive seeds are typically implanted permanently and remain in place; they are not expected to be excreted in the urine.

B. Instruct visitors to stay 1 m (3.3 feet) away from the client: Maintaining a safe distance reduces radiation exposure to others. Visitors, especially pregnant individuals and children, should remain at least 1 meter away to limit exposure while the implant is active.

C. Attach a dosimeter to the client's gown: The dosimeter is worn by staff members, not by the client. It measures cumulative radiation exposure to healthcare workers, ensuring safety guidelines are followed during patient care.

D. Limit each of the client's visitors to 2 hr per day: For low-dose permanent brachytherapy, the radiation levels are generally low, and strict time limits for visitors are usually unnecessary if distance and precautions are observed. Limiting time may apply more to high-dose temporary implants.

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A nurse is teaching a newly licensed nurse about maintaining confidentiality within the nurse-client relationship. The nurse should include that which of the following situations warrants reporting confidential information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Which actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","C","F","G"]

Explanation

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

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