Fundamentals - Basics

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? 1.Elevate HOB 30-45 degrees. 2.Decrease flow rate at night. 3.Check for residual daily. 4.Irrigate regularly with warm tap water

1.Elevate HOB 30-45 degrees.

A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond? 1.Allow the visitor to review the record; sponsors have access to privileged information 2.Ask the primary health care provider about granting permission to the sponsor 3.Do not allow the sponsor to review the record 4.Allow the visitor to review the record; clients with alcoholism need reassurance from sponsors

3.Do not allow the sponsor to review the record

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? 1.All nursing functions will be completed by discharge. 2.All invasive intravenous lines will remain patent. 3.The client will remain awake, alert, and oriented at all times. 4.The client will be free of signs and symptoms of infection by discharge.

4.The client will be free of signs and symptoms of infection by discharge.

A client expresses concern about the surgical consent that the client signed. How should the nurse respond? 1.Share the client's concern with the family 2.Inform the health care provider of the client's concern 3.Reassure the client that the surgery will be successful 4.Cancel the surgery until the client feels more comfortable with the decision

2.Inform the health care provider of the client's concern

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of: 1.Libel 2.Negligence 3.Breach of confidentiality 4.Defamation of character

3.Breach of confidentiality

A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? 1.Tell the family to remove and dispose of the patch. 2.Leave the patch in place for the mortician to remove. 3.Have the family return the patch to the pharmacy for disposal. 4.Remove and dispose of the patch in an appropriate receptacle.

4.Remove and dispose of the patch in an appropriate receptacle.