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 B

Explanation

A. Compare muscle strength bilaterally is not the most immediate concern. Although muscle weakness is a potential sign of hypokalemia, the priority is assessing for cardiac complications, as potassium imbalances can cause life-threatening arrhythmias.

B. Determine apical heart rate and rhythm is the most important intervention. A potassium level of 2.5 mEq/L is dangerously low and can lead to life-threatening cardiac arrhythmias. The nurse should assess the heart rate and rhythm to detect any abnormalities such as bradycardia, tachycardia, or irregular rhythms, which are common in hypokalemia.

C. Observe color and amount of urine is not the priority. While renal function is important, the immediate concern in this case is the potential for severe cardiac complications due to the low potassium level.

D. Assess strength of deep tendon reflexes is important for detecting signs of hypokalemia, but it is secondary to assessing the heart, as potassium imbalances primarily affect cardiac function.

A. Administer a PRN sedative prescription. B. Leave the door to the client's room open slightly. C. Provide a back rub at bedtime. D. Apply wrist restraints to prevent wandering.

Correct Answer is C

Explanation

A. Administer a PRN sedative prescription should not be the first intervention. Non-pharmacological measures, such as promoting relaxation, should be attempted before resorting to medications.

B. Leave the door to the client's room open slightly can help with orientation but does not directly address the client's need for relaxation or sleep.

C. Provide a back rub at bedtime is a non-invasive, calming intervention that can help the client relax and promote sleep. It is appropriate to try this first before escalating to other measures.

D. Apply wrist restraints to prevent wandering is a last resort and should only be used when all other interventions have failed and the client poses a risk to themselves or others. Restraints are not indicated in this scenario without further justification.

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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

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Correct Answer is C

Explanation

To assess the quality of an adult client's pain, which approach should the nurse use?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls," in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

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When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?

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