Problem 1. The nurse is planning a staff education program about client privacy. Which of the following scenarios should the nurse include as an example of a violation of client privacy? 1. discussing with an unlicensed assistive personnel (UAP) that the UAP's assigned client will require a smaller condom catheter 2. sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client to the emergency department (ED) 3. responding to the call light of the client who is assigned to another nurse and needs assistance in the bathroom 4. allowing a nursing student who has been assigned to the client to review the client's medical record
Problem 2. The nurse has become aware of the following client situations. The nurse should first assess the client 1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position while lying on the right side 2. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and reporting hemoptysis 3. who had a wedge resection of the left lung 24 hours ago and is sitting in the high-Fowler's position 4. with heart failure who has a productive cough and is restless
Problem 3. The nurse is caring for a 3-year-old client with a cerebral concussion who is being observed overnight in the pediatric unit. Which of the following observations would be most significant for the nurse to report to the oncoming shift? 1. The client has a blood pressure of 94/58 mm Hg and an apical pulse of 90. 2. The client is sleeping but is easily aroused. 3. The client's pupils are equal and reactive to light. 4. The client has an axillary temperature of 99.0° F (37.2° C) and respirations of 24.
Problem 4. The nurse in the same-day surgical center has received a change-of-shift report on the following clients. The nurse should first see the client who had 1. closed reduction of a fractured tibia with cast application 1 hour ago and is reporting that the casted leg feels hot 2. extraction of a cataract lens 2 hours ago and is reporting nausea 3. an arthroscopy of the right knee 3 hours ago and is reporting knee pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain) 4. a laparoscopic cholecystectomy 4 hours ago and is reporting right shoulder pain