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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.

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Correct Answer is C

Explanation

A. Urinary catheter: A urinary catheter is not routinely required for infants with a spica cast. Unless there are specific urinary retention issues or surgical complications, normal voiding is expected, and a catheter would introduce unnecessary risk for infection.

B. Wound vac: A wound vac is used for complex wound management involving significant drainage or delayed healing. Infants with a spica cast typically do not have open wounds that necessitate negative pressure wound therapy, making this equipment unnecessary for discharge.

C. Car seat: A special car seat or car bed is necessary for safe transportation of an infant in a spica cast, as standard car seats cannot accommodate the wide leg positioning. Proper fitting ensures both safety and compliance with transportation regulations during discharge.

D. Feeding pump: A feeding pump is typically used for clients requiring continuous enteral feeding. Unless the infant has a separate feeding disorder or gastrointestinal complication, feeding by mouth is expected, and a feeding pump would not be standard discharge equipment.

A. Smoking in bed B. Leaving the stove on C. Lack of smoke detectors D. Placing a space heater 5ft from bed

Correct Answer is A

Explanation

A. Smoking in bed: Smoking in bed is a major fire hazard and one of the leading causes of residential fires. Falling asleep with a lit cigarette can easily ignite bedding, mattresses, or upholstered furniture, leading to fast-spreading, deadly fires. This behavior significantly increases the risk of injury or death from residential fires.

B. Leaving the stove on: Leaving the stove unattended can also cause kitchen fires, but cooking-related incidents typically lead to localized fires rather than being the top cause of overall residential fires. Proper supervision while cooking is important, but smoking in bed remains a more dangerous, widespread cause of fatal home fires.

C. Lack of smoke detectors: Lack of smoke detectors does not cause fires but delays detection, increasing the risk of injury or death once a fire has already started. While smoke detectors are crucial for early warning and safety, they are not an ignition source that directly leads to the start of residential fires.

D. Placing a space heater 5ft from bed: Placing a space heater 5 feet away from a bed is generally considered safe, as heaters need clearance but are unlikely to cause fires at that distance. Improper use of space heaters can be hazardous, but when correctly placed, they are not the primary cause of residential fires compared to smoking in bed.

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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 discharge planning of an infant who has a spica cast. Which of the following equipment needs should the nurse identify for discharge?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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