A nurse is updating a postoperative client's plan of care. The nurse should include which of the following as the priority interventions?

Reposition the client frequently.

Instruct the client to use the incentive spirometer.

Increase the amount of time the client spends out of bed each day.

Ensure the client consumes an adequate amount of fluids.

Answer and Explanation

The Correct Answer is B

A.   Reposition the client frequently: While repositioning is important for preventing pressure ulcers and maintaining comfort, it may not be the priority immediately postoperatively compared to other interventions.
B.   Instruct the client to use the incentive spirometer: This is the correct answer. Incentive spirometry helps prevent atelectasis and respiratory complications postoperatively, making it a priority intervention to include in the plan of care.
C.   Increase the amount of time the client spends out of bed each day: Early ambulation is important for preventing complications such as deep vein thrombosis and pneumonia, but it may not be the priority immediately postoperatively depending on the client's condition and surgical procedure.
D.   Ensure the client consumes an adequate amount of fluids: While hydration is important for postoperative recovery, ensuring adequate fluid intake may not be the priority compared to interventions aimed at preventing respiratory complications such as atelectasis.

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Correct Answer is B

Explanation

A. A nurse withholds nutrition from a client who has a do-not-resuscitate (DNR) order:

Withholding nutrition from a client solely based on a DNR order may not align with ethical practice, as nutrition should be provided unless there are specific contraindications or the client has expressed wishes to withhold nutrition.
B. A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min: This is the correct answer. Ethical practice involves providing comfort measures, including appropriate pain management, to clients who are terminally ill and experiencing pain or distress, even if it may inadvertently decrease the respiratory rate.
C. A nurse elects not to care for a client who had an abortion: Refusing to care for a client based on personal beliefs or judgments about their medical history or decisions may not align with
ethical practice, as nurses have a professional obligation to provide nonjudgmental care to all clients.
D. A nurse raises all four side rails on the bed of a client who is confused: While ensuring client safety is important, raising all four side rails without considering the client's individual needs and preferences may not be ethical practice, as it may infringe on the client's autonomy and dignity.

A. A nurse and a provider are discussing a client's condition at the nurses' station while a visitor is present. B. An assistive personnel logs out of the computer prior to responding to a call light. C. A nurse is reviewing an electronic list of all clients admitted to the unit. D. A nurse is faxing data about a client to a referred provider. E. An assistive personnel is informing a friend of the client about their condition.

Correct Answer is ["A","E"]

Explanation

A. This is a breach of confidentiality because discussing a client's condition in a public area where unauthorized individuals can overhear is inappropriate. Confidential information should only be shared in private settings where privacy can be ensured.
B. Logging out of the computer is not a breach of confidentiality; it is a security measure to protect client information.
C. Reviewing an electronic list of clients admitted to the unit is part of routine nursing duties and does not constitute a breach of confidentiality as long as the information is not disclosed to unauthorized individuals.
D. Faxing client data to a referred provider is a part of continuity of care and is not a breach of confidentiality if done following proper protocols to ensure the information is received by the intended recipient.
E. Informing a friend of the client about their condition without consent is a breach of confidentiality. Information about a client's condition should only be shared with individuals who are authorized to receive it, typically those involved in the client's care or those the client has
given permission to be informed.

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A nurse is updating a postoperative client's plan of care. The nurse should include which of the following as the priority interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse provides an annual in-service for the nursing staff regarding ethical practice. Which of the following actions include as an example of ethical practice?

Correct Answer is B

Explanation

A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

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