PN VATI Management proctored
"I cannot allow you access to her medical record unless your mother gives her consent."
The nurse should not release private health information without the client's consent, as this is a
violation of client confidentiality. - ANS-A nurse is caring for a client whose daughter requests to
read her mother's medical record. Which of the following statements should the nurse make?
"I will let your surgeon know that you have decided to cancel,"
The nurse should respect the client's right to refuse treatment. It is the responsibility of the nurse
to notify the surgeon that the client has changed their mind about the surgery. - ANS-A nurse is
caring for a client who is scheduled for an arthroplasty. The client states, "I changed my mind. I
don't want the surgery now." Which of the following responses should the nurse make?
"Il discuss my wishes for my care with my family so they know what I want."
The client should discuss end-of-life care with their family and provider. This will allow the family
to follow the client's advance directives if they can no longer speak for themselves. - ANS-A
nurse is reinforcing teaching with a client about advance directives. Which of the following client
statements should the nurse identify as an indication that the client understands the
information?
"Let's discuss the importance of your breathing treatment."
The nurse should verify that the client understands the reasons for the breathing treatment
along with the benefits and risks. However, the nurse should respect the client's right to refuse. -
ANS-A nurse is preparing to administer a breathing treatment to a client who has COPD. The
client states, "I don't want to have this done. I don't like blowing in my face." Which of the
following responses should the nurse give?
"You can choose to keep your health care information private."
It is the nurse's responsibility to inform the client of their rights, including their right to
confidentiality. A client's health care information should not be shared with others without the
client's consent. - ANS-A nurse is caring for a client who has just received a diagnosis of stage I
lung cancer. The client tells the nurse that she is unsure about sharing the information with her
brother. Which of the following responses should the nurse make?
"You have the right to refuse chemotherapy, but you should understand the risks."
, The nurse should recognize the client's right to refuse treatment and notify the provider to
discuss the risks of refusing treatment with the client. - ANS-A nurse is caring for a client who
has pancreatic cancer. The client tells the nurse that they do not want the chemotherapy the
provider recommended. Which of the following responses should the nurse make?
"You seem upset. Tell me more about their reasons for making this decision."
This is a therapeutic response that demonstrates that the nurse recognizes the partner's
feelings and respects the client's autonomy. - ANS-The partner of a client who has been
receiving dialysis tells the nurse that the client has stated a desire to end treatment. The client's
partner is upset and asks the nurse for help. Which of the following responses should the nurse
make?
"You should encrypt client health information when sending e-mails."
The nurse should encrypt client health information when sending e-mails to protect client
confidentiality. - ANS-A charge nurse is reinforcing teaching with a newly licensed nurse about
maintaining clients' confidentiality. Which of the following statements should the charge nurse
include?
A child who had a tonsillectomy 12 hr ago and is frequently clearing her throat
A child who had a tonsillectomy 12 hr ago and is clearing their throat or swallowing frequently is
unstable: therefore, this client is the highest priority. Frequent clearing of the throat or
swallowing is an indication of postoperative hemorrhage, which requires immediate care. The
nurse should collect additional data from this client first before notifying the provider. - ANS-A
nurse on a pediatric unit is assisting with the care for a group of clients. From which of the
following clients should the nurse collect additional data first?
A client who develops tachycardia
When using the airway, breathing, circulation approach to client care, the nurse's priority is
checking on the client who develops tachycardia to ensure the client is not experiencing
shortness of breath, angina, or shock. - ANS-A nurse is providing care for an assigned group of
clients. Which of the following clients should the nurse see first?
A client who has asymmetrical lung expansion and dyspnea
When using the survival approach to client care, the nurse should give priority immediate
transport. A client who has asymmetrical lung expansion and dyspnea has airway compromise,
which requires immediate intervention for survival. - ANS-A nurse is assisting with triage
following a bus crash that caused multiple casualties. The nurse should identify which of the
following clients as the priority?
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