Try Naxlex NCLEX-RN (Free-Trial)

A nurse on a unit is assisting with the care of a group of clients. Which of the following observations by the nurse requires intervention?

A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for.

A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use.

A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care.

A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report.

Answer and Explanation

The Correct Answer is C

A. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: This is appropriate documentation practice. Nurses are responsible for documenting client information in the EMR when they provide direct care, ensuring accurate and timely records.

B. A nursing colleague printing material that does not contain identifiable information from a client's electronic medical record (EMR) for professional use: If no identifiable client information is included, and it is for professional, educational, or training purposes, this action is acceptable and does not violate confidentiality.

C. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care: Discussing confidential client information with staff not directly involved in the client's care is a violation of HIPAA and breaches client privacy. Only staff responsible for the client's care should access or discuss their health information.

D. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: This is appropriate because handoff reports ensure continuity of care. Discussing necessary client information with the next caregiver is essential for safe, effective client management.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Apply a 9 kg (20 lb) weight to the traction: Buck’s traction is designed for short-term immobilization and uses lighter weights, typically between 2 to 5 kg (4.5 to 10 lb). Applying 9 kg (20 lb) would be excessive and could lead to nerve damage, impaired circulation, or additional injury.

B. Clean the pin insertion sites on a daily basis: Buck’s traction is a type of skin traction, not skeletal traction, and does not involve pins inserted into the bone. Therefore, there are no pin sites to clean in Buck’s traction, making this action irrelevant for the client’s care.

C. Remove the weights while the client is eating: Weights should never be removed or lifted unless there is a provider’s specific order to do so. Interrupting the continuous pull of the traction can cause misalignment of the fracture and delay healing.

D. Ensure that the weights are hanging freely: It is essential that the weights in Buck’s traction hang freely without resting on the floor or bed. This ensures a constant, steady pull on the extremity, which helps maintain proper alignment and promotes effective immobilization.

A. Amyloid plaque B. Urinary tract infection C. High cholesterol D. Hypersomnia

Correct Answer is B

Explanation

A. Amyloid plaque: Amyloid plaque buildup is characteristic of Alzheimer’s disease, a chronic, progressive form of dementia. While dementia can increase the overall risk for delirium, amyloid plaques themselves are not an immediate trigger for acute confusion like delirium.

B. Urinary tract infection: Urinary tract infections are a common reversible cause of delirium, especially in older adults. Infections can trigger a systemic inflammatory response and disrupt normal brain function, leading to sudden-onset confusion, disorientation, and restlessness due to systemic inflammation and changes in metabolic balance.

C. High cholesterol: High cholesterol contributes to long-term cardiovascular risks, such as atherosclerosis and stroke, but it is not directly linked to the sudden cognitive changes seen in delirium. It does not cause the acute neurological dysfunction characteristic of delirium.

D. Hypersomnia: Hypersomnia, or excessive daytime sleepiness, may reflect underlying sleep disorders or other chronic conditions, but it is not recognized as a common direct cause of delirium. Acute changes in mental status are more often tied to factors like infection, medications, or metabolic disturbances.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Body System	Findings
Cardiovascular	S1, S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat (HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg

A nurse on a unit is assisting with the care of a group of clients. Which of the following observations by the nurse requires intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

Correct Answer is B

Explanation

A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?

A nurse is reinforcing teaching with a client on measures to promote their sleep. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting with the admission of an infant who has experienced vomiting and loose, watery stools for the past 3 days. Which of the following findings indicates that the child is experiencing moderate dehydration?

A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (APIT