Nursing Elites

1. A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?

• A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse.
• B. A nurse asks a nurse from another unit to assist with her documentation.
• C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care.
• D. A nurse discusses a client's status with the physical therapist who is caring for the client at the bedside.

Correct answer: B

Rationale: The correct answer is B. HIPAA guidelines specify that only healthcare professionals directly involved in a patient's care should access their medical information. Asking a nurse from another unit to assist with documentation involves sharing patient information with someone not directly caring for the patient, which violates HIPAA guidelines. Choices A, C, and D involve individuals directly involved in the client's care, making them appropriate actions in line with HIPAA regulations. Choice A involves educating a nursing student under the supervision of the nurse, which is permissible. Choice C involves communicating with the client's designated healthcare decision-maker, which is also allowed under HIPAA. Choice D involves discussing the client's status with another healthcare professional directly involved in the client's care, which is within HIPAA guidelines.

2. A client who is malnourished expresses concern about losing their loose wedding ring. What is the most appropriate action for the nurse to take?

• A. I can pin it to your hospital gown to prevent it from falling off.
• B. I will place it in your drawer to keep it safe.
• C. I will hold onto it until a family member can retrieve it.
• D. I can put it in a locked storage unit for you.

Correct answer: D

Rationale: The most appropriate action for the nurse to take is to put the client's wedding ring in a locked storage unit for safekeeping. This ensures that the ring is secure and minimizes the risk of loss or damage. Choices A, B, and C do not provide the same level of security and protection as placing the ring in a locked storage unit. Pinning it to the hospital gown (Choice A) may not be secure and could still lead to loss. Placing it in the client's drawer (Choice B) may not guarantee its safety. Holding onto it until a family member retrieves it (Choice C) leaves the ring vulnerable to misplacement or theft.

3. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

• A. Gently shake the container of medication prior to administration
• B. Transfer the medication to a medicine cup
• C. Place the client in a semi-Fowler’s position for medication administration
• D. Verify the dosage by measuring the liquid before administering it

Correct answer: A

Rationale: The correct action for the nurse to take is to gently shake the container of liquid medication before administration. Shaking the container ensures proper mixing of the medication, which is important to maintain uniformity of the dose. Transferring the medication to a medicine cup (choice B) may not be necessary for a small volume like 0.5 mL. Placing the client in a semi-Fowler's position (choice C) is not directly related to administering liquid medication orally. Verifying the dosage by measuring the liquid (choice D) is important but does not address the specific action needed to prepare the medication for administration.

4. The healthcare professional is preparing to administer a medication through a nasogastric (NG) tube. Which action should the healthcare professional take to ensure proper administration?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Administer the medication with food to prevent nausea.
• C. Verify tube placement by aspirating stomach contents.
• D. Dilute the medication with normal saline before administration.

Correct answer: A

Rationale: Flushing the NG tube with water before and after medication administration is essential to ensure the tube is patent and prevent clogging. This action helps in clearing the tube and ensures that the medication is delivered properly. Administering medication with food (Choice B) may not be appropriate for all medications and can interfere with their absorption. Verifying tube placement by aspirating stomach contents (Choice C) is important but does not directly relate to ensuring proper medication administration. Diluting the medication with normal saline (Choice D) is not a standard practice for administering medications through an NG tube.

5. When measuring a client's blood pressure, which approach is the priority for a nurse caring for a client with hypertension?

• A. Obtain the blood pressure under the same conditions each time
• B. Use a different arm for each measurement
• C. Measure the blood pressure while the client is standing
• D. Take multiple readings at different times of the day

Correct answer: A

Rationale: The correct approach when measuring a client's blood pressure, especially for a client with hypertension, is to obtain the blood pressure under the same conditions each time. Consistency in measurement conditions helps ensure accurate and comparable blood pressure readings. Using a different arm for each measurement (Choice B) is not ideal as it can lead to variations in readings. Measuring the blood pressure while the client is standing (Choice C) is not the standard practice and may not provide accurate results. Taking multiple readings at different times of the day (Choice D) may be useful for monitoring blood pressure trends but is not the priority when ensuring accurate individual readings.

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