The nurse educators on a cardiovascular unit of a health care facility are creating a social media project that addresses improving outcomes for clients with heart failure. Which action should the nurses implement to protect client privacy?

Remove client identifying information of those who participate.

Implement full disclosure policy especially when giving examples.

Respect all copyright laws when adding website content.

May use information from the client's relatives instead.

Answer and Explanation

The Correct Answer is A

A. Remove client identifying information of those who participate is correct because protecting client confidentiality is a fundamental principle of ethical nursing practice. De-identifying data ensures compliance with privacy regulations like HIPAA.

B. Implement full disclosure policy especially when giving examples is not appropriate as sharing identifiable client information, even with disclosure, violates privacy laws.

C. Respect all copyright laws when adding website content is important but does not directly address client privacy, which is the primary concern in this scenario.

D. May use information from the client's relatives instead still violates privacy laws if the information is related to the client’s care, even if shared by relatives.

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Correct Answer is D

Explanation

A. Complete an adverse occurrence/incident report may be necessary if harm occurs, but the priority is to immediately correct the unsafe practice to prevent injury.

B. Ensure that the restraints are not too tight is important, but addressing the incorrect technique of securing restraints to the bedside rails takes precedence as it poses a greater risk to the client’s safety.

C. Initiate the facility's restraint flow sheet is part of documentation but does not address the immediate safety concern.

D. Demonstrate proper securing of the restraints is correct because restraints should never be secured to movable parts of the bed, such as the rails, as this can cause injury. The nurse must provide immediate education to the UAP to prevent harm and ensure the restraints are applied correctly.

A. Report any change in urine color. B. Keep mucous membranes moist. C. Record the client's daily weight. D. Maintain in high Fowler's position.

Correct Answer is B

Explanation

A. Report any change in urine color is not a primary intervention in palliative care for this client. While monitoring urine output is important in assessing hydration status, it does not directly address the client's comfort, which is a key goal in palliative care.

B. Keep mucous membranes moist is a critical intervention for this client. Mouth breathing and the refusal of fluids can lead to dry mucous membranes, causing discomfort. Regular oral care using swabs or rinses can alleviate dryness, improving the client's comfort and quality of life.

C. Record the client's daily weight is unnecessary in this situation. Monitoring weight is typically relevant for clients whose fluid balance or nutritional status is being managed, which is not a focus in palliative care for a terminally ill client.

D. Maintain in high Fowler's position is not the priority in this scenario. While positioning may be adjusted to support breathing, the focus should remain on comfort, such as alleviating the dryness associated with mouth breathing.

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The nurse educators on a cardiovascular unit of a health care facility are creating a social media project that addresses improving outcomes for clients with heart failure. Which action should the nurses implement to protect client privacy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is D

Explanation

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit (ICU). The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

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