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The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is
helping the nurse. Which task is important for the nurse to perform, rather than
the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
C.Obtain the client's height and weight.
D.Offer the client emotional support.
D
By using therapeutic techniques to offer support (D), the nurse can
determine any client concerns that need to be addressed. (A, B, and C) are all
actions that can be performed by the UAP under the supervision of the nurse.
,A client who is admitted with emphysema is having difficulty breathing. In which
position should the nurse place the client?
A.High Fowler's position without a pillow behind the head
B.Semi-Fowler's position with a single pillow behind the head
A. Right side-lying position with the head of the bed elevated 45 degrees
D.Sitting upright and forward with both arms supported on an over the bed table
D
Adequate lung expansion is dependent on deep breaths that allow the
respiratory muscles to increase the longitudinal and anterior-posterior size of
the thoracic cage. Sitting upright and leaning forward with the arms
supported on an over the bed table (D) allows the thoracic cage to expand in all
four directions and reduces dyspnea. A high Fowler's position does not allow
maximum expansion of the posterior lobes of the lungs (A). A semi-Fowler's
position restricts expansion of the anterior-posterior diameter of the thoracic
cage (B). Positioning a client on the right side with the head of the bed elevated
(C) does not facilitate lung expansion.
,The nurse is obtaining a client's sexual history. Which finding requires additional
follow-up regarding the client's self-image?
A. Sexual intercourse with the spouse occurs four times a week.
B. The spouse has never seen the client naked.
C. The client has had surgery for permanent birth control.
D. A history of a 20-lb weight loss occurred in the past year.
B
It is usual for spouses to see each other without clothing, so a follow-up
question about (B) should provide additional information about the client's
self-concept and body image. (A and C) are choices within the continuum of normal
and acceptable sexual needs based on each couple's preferences.
Body image is a perception of one's physical self and weight gain or loss
normally affects one's self-image (D).
, Which situation demonstrates proper application of client confidentiality
requirements for the Health Insurance Portability and Accountability Act
(HIPAA)?
A. Clients' names are not used while they are in a public waiting room.
B. Nurses should not recommend any community self-help groups by
specific name, such as Alcoholics Anonymous.
C. Clients must pick up their filled prescriptions from a pharmacy in person with
a photo identification card.
D. Old medical records are kept in a locked file cabinet in the department.
D
Past medical records must be "secured" and "reasonably protected" from
inadvertent viewing (D). A locked room or file cabinet can serve this purpose,
and when any protected health information (PHI) is discarded, it must be
shredded. A person's name only (without their diagnosis or
treatment) is not considered confidential or PHI (A). Nurses may suggest
categories of community resources, with examples, such as Alcoholics
Anonymous (B), but cannot market a specific program in which they have a
financial interest. Others can pick up a client's filled prescriptions (C).