A nurse on a medical unit is admitting a client.

Exhibits

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Nurses' Notes

Day 1, 1600:

Client admitted from provider's clinic reporting shortness of breath, dry hacking cough, dizziness, and "heart racing."

States they are not able to sleep well on their back at night because of difficulty breathing.

Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 130/min, ECG monitor showing sinus tachycardia, S1, auscultated. Lower extremity edema noted, 2+ bilaterally, Radial and pedal pulses 1+ bilaterally.

Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.

Client reports gaining 10 pounds in the past month.

Reports history of type 2 diabetes mellitus and hypertension.

Heart rate 130/min

ECG monitor showing sinus tachycardia

edema

Breathing rapid and shallow. Crackles

gaining 10 pounds in the past month.

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

Correct answers:

Nurses Notes Day 1, 1600:
Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 150/min, ECG monitor showing sinus tachycardia, 5, auscultated. Lower extremity edema noted, 2+ bilaterally. Radial and pedal pulses 1 bilaterally. Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.
Client reports gaining "10 pounds in the past month."

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. A suction device is necessary for the nasogastric tube insertion procedure to remove gastric contents and ensure the tube is correctly placed in the stomach.
B. An infusion pump is not typically required for nasogastric tube insertion.
C. A disposable feeding bag is used for enteral feeding and is not directly related to the insertion of a nasogastric tube.
D. Sterile gloves are not typically used during nasogastric tube insertion, as it is a clean procedure rather than a sterile one.

A. "The actual medical record belongs to the client." B. "A client's medical record information remains confidential, even during an emergency." C. "If the client dies, their family receives their medical record." D. "A client has the right to view their medical record."

Correct Answer is B

Explanation

A. Incorrect. While clients have rights to access their medical records, ownership of the actual record typically remains with the healthcare provider or facility.
B. Correct. The HIPAA Privacy Rule mandates that a client's medical information remains confidential and protected, even during emergencies or when disclosed to other healthcare providers for treatment purposes.
C. Incorrect. In most cases, access to a deceased client's medical records is restricted to authorized individuals, such as next of kin or legal representatives, and is subject to privacy laws. D. Incorrect. While clients have the right to view their medical records under HIPAA, this statement does not specifically address the confidentiality aspect of the Privacy Rule.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client who has a small bowel obstruction for insertion of a nasogastric tube. Which of the following equipment should the nurse gather prior to the procedure?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about the HIPAA Privacy Rule. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has a cast on their left lower leg. Which of the following actions should the nurse take?

Patient Data Exhibits

A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying. Which of the following actions should the nurse take to reduce the risk of aspiration?

A nurse is caring for a client who is near death. Which of the following actions should the nurse take?

A nurse is caring for a client who is using a non-rebreather mask for oxygen delivery. The nurse should identify which of the following as an indication that the equipment is functioning properly?

A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?

A nurse is preparing to remove a peripheral IV for a preschooler. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is assisting in the development of an in-service for staff members about physical abuse of children. Which of the following children are at an increased risk for physical abuse?