When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

Record the client's pulse rate and rhythm.

Assist the client to stand at the bedside.

Apply the blood pressure cuff securely.

Position the client supine for a few minutes.

Answer and Explanation

The Correct Answer is D

Choice A reason: Recording the client's pulse rate and rhythm is part of the assessment, but it is not the first action to take when assessing for orthostatic hypotension.
Choice B reason: Assisting the client to stand is part of the assessment process, but it should be done after the initial blood pressure and pulse have been measured while the client is supine.
Choice C reason: Applying the blood pressure cuff securely is necessary for an accurate reading, but it is not the first step in the process of assessing for orthostatic hypotension.
Choice D reason: The first action is to position the client supine for a few minutes before taking the initial blood pressure and pulse measurements, as this provides a baseline for comparison when the client stands.

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Correct Answer is B

Explanation

Choice A reason: While fitting for an N95 mask is important, it is not required for droplet precautions, which are appropriate for meningococcal infections.

Choice B reason: For meningococcal infections, droplet precautions, including a standard face mask, are recommended for the first 24 hours of antimicrobial therapy.

Choice C reason: It is the responsibility of the healthcare facility to ensure that all staff members who require it are fitted for particulate filter masks, but this does not apply to droplet precautions for meningococcal infections.

Choice D reason: Sending the UAP for an immediate fitting for a particulate filter mask is unnecessary for droplet precautions and could delay essential care for the client.

A. Describing a client's illness in the breakroom without mentioning a name. B. Discussing health history with the client behind a closed curtain. C. Faxing health records to the client's primary healthcare provider. D. Sharing a client's discharge needs with other treatment team members.

Correct Answer is A

Explanation

Choice A reason: Even without mentioning the client's name, discussing health information in a public area like a breakroom can still lead to a HIPAA violation due to the possibility of revealing identifiable information indirectly.

Choice B reason: Discussing health history with a client behind a closed curtain maintains privacy and confidentiality, adhering to HIPAA regulations.

Choice C reason: Faxing health records to a client's primary healthcare provider is a common practice and is not a HIPAA violation if done securely and with proper consent.

Choice D reason: Sharing a client's discharge needs with other treatment team members is necessary for continuity of care and is not a HIPAA violation as long as it is done within the healthcare team.

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When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?

Correct Answer is B

Explanation

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

Correct Answer is A

Explanation

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