PN Fundamentals NGN

The correct answer is B: tell the nurses that this conversation is not appropriate.

Explanation of the correct answer:

B. Tell the nurses that this conversation is not appropriate.

The nurse should immediately intervene and address the inappropriate conversation. Discussing patient information, even indirectly or in casual conversation, is a violation of patient privacy and confidentiality. The nurse should remind the colleagues that discussing patient details outside of a confidential setting, such as in a public space like an elevator, is unprofessional and goes against the principles of patient confidentiality. This action serves to directly correct the behavior while emphasizing the importance of maintaining confidentiality in all situations.

Why the other options are incorrect:

A. Inform the nurses that the neighbor's dog did not cause the wound.

While the content of the conversation might be incorrect, the main issue here is the discussion of patient details in a public space. Correcting the factual inaccuracy in this context is secondary to addressing the violation of confidentiality.

C. Complete an incident report upon returning to the unit.

While completing an incident report could be necessary if the nurse observes a violation of policy or law, the first action should be directly addressing the inappropriate conversation. Reporting the incident can follow after the situation has been addressed, but immediate action to stop the inappropriate behavior is more important.

D. Report the nurses' conversation to the client's provider.

Reporting the nurses' conversation to the client’s provider is not necessary at this stage. The primary responsibility is to stop the inappropriate conversation immediately and address the confidentiality breach. The provider should not be involved unless there is a more serious issue or continued violation.

Summary:

The most appropriate action is to directly intervene and tell the nurses that their conversation is not appropriate, as discussing patient information in public violates patient confidentiality. The other options involve actions that are either too delayed or not as directly related to addressing the behavior at hand.

The correct answers are

b: Family members should provide a code prior to receiving client health information,

d. A client can request a copy of their medical record,

e. A nurse can photocopy a client's medical record for transfer to another facility.

Explanation of the correct answers:

b. Family members should provide a code prior to receiving client health information.

This is a HIPAA requirement for safeguarding patient privacy. Family members who wish to obtain health information about a client need to provide a pre-established code or have the client give explicit consent to share that information. This ensures that client information is only disclosed to authorized individuals, maintaining confidentiality.

d. A client can request a copy of their medical record.

Under HIPAA, clients have the right to access their health records. They can request a copy of their medical record for review, and healthcare organizations are required to provide access in a timely manner, typically within 30 days. The client’s right to their own medical records is a key element of HIPAA.

e. A nurse can photocopy a client's medical record for transfer to another facility.

HIPAA allows the transfer of medical records between healthcare facilities when necessary for patient care, provided that proper authorization is obtained. A nurse can photocopy or electronically send medical records, but only with the appropriate consent or transfer agreements in place, ensuring that the transfer is secure and the client’s privacy is protected.

Why the other options are incorrect:

a. A single electronic records password is provided for nurses on the same unit.

This practice violates HIPAA because it compromises the confidentiality and security of client information. Each healthcare professional should have their own unique login credentials to ensure accountability and limit unauthorized access to medical records. Sharing passwords, even within a unit, is not compliant with HIPAA privacy and security regulations.

c. Communication of client information can occur at the nurses' station.

This statement is problematic under HIPAA. While communication of client information may need to occur at the nurses' station, it should be done in a private and secure manner. Discussing private client information openly in common areas or in the presence of unauthorized individuals violates HIPAA privacy rules. Staff should always ensure that discussions of client health information take place in a confidential setting.

Summary:

To ensure compliance with the HIPAA Privacy Rule, a nurse manager should emphasize the importance of client confidentiality, the right of clients to access their medical records, the necessity of secure transfer of medical records, and proper procedures for disclosing client information to family members. The options b, d, and e are correct and align with HIPAA guidelines.

The correct answer is B: flashing smoke alarm.

Explanation of the correct answer:

B. Flashing smoke alarm

The priority modification to the home environment for a client with partial hearing loss is a flashing smoke alarm. Clients with hearing loss may not be able to hear traditional smoke alarms that emit high-pitched sounds. A flashing light (often a strobe light) provides a visual signal of a fire or emergency, ensuring the client is alerted to a potential life-threatening situation, especially when asleep or in a different room. This modification is critical for safety and emergency preparedness.

Why the other options are incorrect:

A. Alarm clock that shakes the bed

While an alarm clock that shakes the bed is helpful for waking up, it is not a safety-related modification. In emergency situations like a fire, the flashing smoke alarm takes precedence, as it ensures the client is alerted in time to escape danger.

C. Low-pitched buzzer doorbell

A low-pitched buzzer doorbell might be useful for hearing individuals, but a vibrating or visual alert system would be more beneficial for a client with hearing loss. Vibrating doorbells or visual signals (like flashing lights) are more effective than low-pitched sounds for those with partial hearing loss.

D. Telephone with an amplified receiver

While an amplified receiver telephone is beneficial for communication, it is not as crucial as the flashing smoke alarm for the safety of the client in case of an emergency. Amplified telephones enhance communication, but the client’s safety in an emergency situation is the priority.

Summary:

For a client with partial hearing loss, the nurse should prioritize a flashing smoke alarm to ensure the client is alerted during emergencies, as hearing loss may prevent the detection of audible alarms. This safety measure is the most critical for the client's well-being.

The correct answer is B: Latex.

Explanation of the correct answer:

Latex allergy is a critical concern when preparing for IV therapy, as many medical supplies, such as IV tubing, gloves, and catheter hubs, are made from latex. A latex allergy can result in severe allergic reactions, including anaphylaxis. Therefore, the nurse must immediately inform the charge nurse about the client’s latex allergy before initiating IV therapy to ensure that non-latex alternatives are used for all equipment.

Why the other options are incorrect:

A. Eggs

An egg allergy is typically related to the consumption of eggs or products containing egg-derived ingredients. It is not directly relevant to IV therapy unless the client is being prescribed medications or vaccines that contain egg proteins, which are less common in the administration of IV fluids. However, it is not an immediate concern in the context of standard IV therapy unless specified by the prescribing provider.

C. Seafood

A seafood allergy primarily affects the digestive system and is typically a concern when the client consumes seafood or is exposed to seafood proteins. It is generally not a significant concern in IV therapy unless the client is receiving specific medications or contrast dyes that might contain seafood-based ingredients, which is rare. Therefore, this is not a priority allergy to address in the immediate context of initiating IV therapy.

D. Bee stings

A bee sting allergy is a concern for reactions related to insect stings but is not typically relevant to the administration of IV therapy. Although the client’s allergy history should always be documented, bee sting allergies do not directly affect the care process for initiating an IV unless the client is exposed to environmental factors that trigger such reactions.

Summary:

The nurse should bring a latex allergy to the charge nurse’s attention before initiating IV therapy, as latex products are commonly used in IV equipment and can cause serious allergic reactions. The other allergies are less directly related to the administration of IV therapy. Therefore, the correct answer is B. Latex.

The correct answer is B: Dorsalis pedis.

Explanation of the correct answer:

B. Dorsalis pedis

The dorsalis pedis pulse is located on the top (dorsum) of the foot. To palpate it, the nurse should place the fingers of one hand gently on the top of the foot, just lateral to the extensor tendon of the big toe. This pulse is part of the arterial system of the foot and can be used to assess the circulation in the lower extremity, especially in individuals who might have conditions like peripheral artery disease (PAD) or diabetes, which can impair circulation.

How to find the dorsalis pedis pulse:

The nurse should ask the client to relax their foot. Then, using their index and middle fingers, gently palpate the top of the foot, slightly lateral to the big toe's tendon. The pulse should be strong and regular, indicating good circulation to the foot.

Why the other options are incorrect:

A. Posterior tibial

The posterior tibial pulse is located on the inside (medial side) of the ankle, just behind the medial malleolus, which is the bony prominence on the inner ankle. To palpate this pulse, the nurse should place their fingers just behind the ankle bone. The posterior tibial pulse is used to assess blood flow to the foot and lower leg but is not located on the top of the foot.

How to find the posterior tibial pulse:

The nurse should palpate the inner side of the ankle, just behind the medial malleolus, and press gently to feel the pulse. This is another important pulse used for circulation assessments, but it is not on the top of the foot.

C. Popliteal

The popliteal pulse is located behind the knee in the popliteal fossa. This pulse can be difficult to palpate, especially in obese patients, and is assessed when the knee is slightly bent to relax the muscles in that area. It is crucial for evaluating blood flow to the lower extremity but is not located on the top of the foot.

How to find the popliteal pulse:

The nurse should ask the client to lie down with their knee slightly bent. Place the fingers behind the knee in the popliteal fossa and gently palpate. This pulse is important for circulation to the lower leg and foot but does not appear on the foot itself.

D. Brachial

The brachial pulse is located on the inner aspect of the upper arm, just above the elbow crease. It is most commonly used when measuring blood pressure or assessing circulation to the arm. It is not located anywhere near the foot.

How to find the brachial pulse:

To palpate the brachial pulse, the nurse places their fingers on the inner side of the upper arm, just above the elbow. This pulse is used in blood pressure measurements but is not relevant to the foot or its circulation.

Summary:

The dorsalis pedis pulse is located on the top of the foot, specifically lateral to the tendon of the big toe. This pulse is used to assess circulation in the lower extremity, making it the correct answer in this case.

The posterior tibial pulse is found behind the medial malleolus (inside of the ankle), the popliteal pulse is found behind the knee, and the brachial pulse is found in the upper arm, none of which are located on the top of the foot.

Understanding the locations of these pulses helps in evaluating the blood flow to different parts of the body, which is critical for managing conditions that affect circulation.

The correct answer is D: positive Chvostek's sign.

Explanation of the correct answer:

D. Positive Chvostek's sign

A positive Chvostek’s sign is a classic and early indication of hypomagnesemia, as well as hypocalcemia. It is identified by twitching of the facial muscles in response to tapping over the facial nerve, just anterior to the ear. This reaction occurs because low magnesium levels increase neuromuscular excitability. Magnesium is essential for the normal function of muscles and nerves, and when it drops too low, the nervous system becomes more excitable, leading to symptoms like:

Twitching

Tremors

Muscle cramps

Tetany

Seizures (in severe cases)

Clients with nasogastric (NG) tubes set to low intermittent suction are at increased risk of electrolyte imbalances, particularly magnesium, potassium, and calcium loss. This is due to the continuous removal of gastric contents, which contain essential electrolytes. Over time, the depletion of these electrolytes can manifest with clinical signs such as Chvostek’s sign, especially when magnesium is low.

Why the other options are incorrect:

A. Bone pain

Bone pain is not characteristic of hypomagnesemia. It is more commonly associated with conditions like:

Osteomalacia or osteoporosis

Vitamin D deficiency

Bone metastases or cancer

Hyperparathyroidism

Magnesium deficiency affects neuromuscular function, not bone integrity directly.

B. Drowsiness

Drowsiness is typically linked to hypermagnesemia, where high magnesium levels depress the central nervous system. In contrast, hypomagnesemia tends to increase excitability, resulting in symptoms like irritability, tremors, and muscle twitching—not sedation.

C. Bowel hypomotility

Hypomagnesemia may actually lead to increased bowel activity in some cases, not hypomotility. Additionally, hypokalemia or hypercalcemia are more likely causes of bowel hypomotility or paralytic ileus. A sluggish bowel is not a recognized early sign of magnesium deficiency.

Summary:

In clients with an NG tube on suction, the removal of gastric fluids can cause magnesium depletion. A positive Chvostek's sign is a key clinical finding that points to hypomagnesemia, due to increased neuromuscular excitability. This makes it the most appropriate and accurate indicator among the options provided.

The correct answer is A: Clean the perineal area at least once a day.

Explanation of the correct answer:

A. Clean the perineal area at least once a day

Proper hygiene is critical for preventing urinary tract infections (UTIs) in clients with indwelling urinary catheters. The perineal area should be cleaned at least once a day, and more frequently as needed, to reduce the risk of infection. Cleaning the catheter insertion site and the surrounding perineal area at regular intervals helps maintain hygiene and prevents bacterial buildup, which can lead to infections. The frequency of cleaning should be guided by the client's needs and the facility's infection control policies.

Why the other options are incorrect:

B. Empty the drainage bag when it is three-fourths full

Emptying the drainage bag when it is three-fourths full is a good practice for maintaining proper catheter care, but it is not the correct answer in this context because cleaning the perineal area is directly related to infection prevention. The recommendation to empty the drainage bag regularly is still valid, but cleaning the perineal area at least once a day should be the priority action.

C. Flush the catheter with sterile water daily

Flushing the catheter with sterile water is not generally recommended as a routine practice unless there is a specific medical indication, such as blockage or to clear a clot. Flushing should be done as ordered by the healthcare provider, not on a daily basis. Routine flushing without indication can increase the risk of infection or trauma to the catheter or bladder.

D. Disconnect the drainage bag when emptying and measuring urine

Disconnecting the drainage bag from the catheter increases the risk of infection by breaking the closed system. The catheter system should remain closed to reduce the risk of contamination. The correct procedure is to empty the drainage bag without disconnecting it from the catheter to maintain sterility and prevent infection.

Summary:

The most appropriate action is to clean the perineal area at least once a day to prevent infection in clients with indwelling urinary catheters. Regular hygiene around the catheter site is key to infection prevention. While other actions such as emptying the drainage bag and avoiding disconnection of the catheter system are important, they do not directly address the perineal care, which is crucial for reducing infection risk. Therefore, the correct answer is A. Clean the perineal area at least once a day.

The correct answer is B: Hyponatremia.

Rationale: Vomiting and diarrhea can lead to the loss of both water and electrolytes, including sodium, potassium, and chloride. This loss can result in various imbalances, and hyponatremia (low sodium levels) is the most likely finding in a client who has been vomiting and experiencing diarrhea for 2 days. Sodium is an essential electrolyte that helps maintain fluid balance, and excessive loss can lead to hyponatremia, which can cause symptoms such as headache, nausea, confusion, and muscle cramps.

Why the other options are incorrect:

A. Hypermagnesemia:

Hypermagnesemia (elevated magnesium levels) is unlikely to occur as a result of vomiting and diarrhea. Diarrhea typically leads to the loss of magnesium, and vomiting primarily causes the loss of potassium and sodium, not magnesium. Therefore, hypermagnesemia is not typically associated with vomiting and diarrhea.

C. Hypocalcemia:

While vomiting and diarrhea can cause various electrolyte imbalances, hypocalcemia (low calcium levels) is not a typical finding in these cases. Calcium levels are more commonly affected by conditions like parathyroid disorders or kidney failure, but it is less likely to be significantly altered by vomiting and diarrhea alone.

D. Hyperkalemia:

Hyperkalemia (elevated potassium levels) is not typically seen in vomiting and diarrhea. In fact, both vomiting and diarrhea cause the loss of potassium, which could lead to hypokalemia (low potassium levels), not hyperkalemia. Potassium imbalances, particularly hypokalemia, are common in clients with prolonged vomiting and diarrhea.In summary:

Vomiting and diarrhea commonly result in hyponatremia due to the loss of sodium and other electrolytes. Therefore, B. Hyponatremia is the correct answer

The correct answer is A: apply thromboembolic stockings.

Explanation of the correct answer:

A. Apply thromboembolic stockings

Applying thromboembolic stockings (TED hose or compression stockings) is within the scope of practice for assistive personnel (AP). The AP can assist by applying these stockings as they help improve circulation and prevent thrombus formation by applying gentle compression to the legs, which aids in venous return and reduces the risk of deep vein thrombosis (DVT). The nurse should provide clear instructions on the proper application, but the actual task of applying these stockings can be safely delegated to the AP.

Why the other options are incorrect:

B. Monitor the circulation in all four extremities

Monitoring circulation in all four extremities requires clinical judgment and the ability to assess vital signs, skin color, temperature, pulses, and other indicators of circulation. This responsibility requires the expertise of a nurse, as it involves interpreting findings and deciding on appropriate interventions, making it inappropriate for delegation to an AP.

C. Record the condition of the client's skin

While APs may observe and report findings about the skin condition, recording the condition requires professional nursing judgment and documentation in the medical record. It is a critical aspect of care that involves clinical decision-making, so it should be performed by the nurse, not delegated to the AP.

D. Reinforce teaching about performing range-of-motion exercises

While the AP can assist with range-of-motion exercises, teaching is an aspect of care that requires the nurse’s expertise. The nurse is responsible for the initial education, including assessing the client’s understanding and answering questions. Reinforcing teaching can be done by the AP if it is directly related to the basic steps of the exercise, but the nurse should ensure that the information is being communicated correctly and comprehensively.

Summary:

The task of applying thromboembolic stockings can safely be delegated to an AP, as it is a straightforward task that does not require clinical judgment. Other tasks, such as monitoring circulation, recording skin condition, and reinforcing teaching, require the professional skills of the nurse.