The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions.
Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?

Shares the health history with case manager.

Discusses diagnoses with the physical therapist.

Provides a list of food allergies to nutritional services.

Requests military records by phone.

Answer and Explanation

The Correct Answer is D

Requesting military records by phone without the patient’s consent would be a breach of confidentiality.

Choice A is incorrect because sharing the health history with a case manager who is involved in the patient’s care would not be a breach of confidentiality.

Choice B is incorrect because discussing diagnoses with a physical therapist who is involved in the patient’s care would not be a breach of confidentiality.

Choice C is incorrect because providing a list of food allergies to nutritional services who are involved in the patient’s care would not be a breach of confidentiality.

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Correct Answer is B

Explanation

Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.

When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.

Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.

In fact, it is recommended that you brush your teeth at least once every four hours1.

Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.

Choice D is incorrect because positioning the unconscious client upright is not the best method.

Instead, they should be placed in a side-lying position to prevent aspiration1.

A. Review the chart for number of voids over the last 24 hours. B. Evaluate the client for urinary incontinence. C. Scan the client's bladder after voiding. D. Palpate the suprapubic region for distention.

Correct Answer is C

Explanation

This will help determine if there is any residual urine left in the bladder after voiding.

Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.

Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.

Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.

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The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions. Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning to provide mouth care to an unconscious client. Which statement is accurate for implementing mouth care to this client?

Correct Answer is B

Explanation

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

Correct Answer is C

Explanation

The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago. Which intervention should the nurse implement next?

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

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The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions.
Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?