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. Record a palpable systolic pressure of 90 mm Hg is premature because the nurse has not yet completed the process of determining the systolic blood pressure.

B. Inflate blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse disappears to ensure accurate measurement of the systolic blood pressure.

C. Release the manometer valve immediately would not allow the nurse to accurately determine the systolic blood pressure. The valve should be released slowly to palpate the return of the pulse.

D. Document the absence of the radial pulse is unnecessary because the disappearance of the pulse is a normal part of the procedure when obtaining a systolic blood pressure by palpation.

A. Restrict oral fluid intake. B. Offer to warm the prune juice. C. Advance to a regular diet. D. Initiate bowel training protocol.

Correct Answer is D

Explanation

A. Restrict oral fluid intake is not appropriate in this situation. Decreased bowel sounds and constipation may indicate a need for hydration, not restriction of fluids. Fluids are essential to help prevent and alleviate constipation.

B. Offer to warm the prune juice may be helpful in some cases to encourage the client to drink, but it does not address the underlying issue of constipation and decreased bowel sounds. A more comprehensive intervention, such as bowel training, is needed.

C. Advance to a regular diet may not be appropriate without assessing the client's tolerance for additional food types. The client is on a mechanical soft diet, which may already be sufficient. Advancing to a regular diet could potentially exacerbate the constipation.

D. Initiate bowel training protocol is the most appropriate action. Bowel training is designed to help manage constipation and promote regular bowel movements. This may include dietary adjustments, increased fluid intake, and other measures such as scheduled toileting.

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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 is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is B

Explanation

A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

Correct Answer is D

Explanation

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)]

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?

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