71. Key: C Client Need: Pharmacological and Parenteral Therapies
C. Rotation of the injection site will help to minimize ecchymosis.
A. Massaging the injection site will increase the likelihood of ecchymosis.
B. This technique is used for administration of medication into deep muscles.
D. Aspirating prior to injection will increase the likelihood of ecchymosis.
72. Key: C Client Need: Management of Care
C. An occlusive dressing should be applied to prevent air from entering the chest cavity. It should be the nurse’s first action.
A, B & D. These actions can be done after reestablishing closed chest system.
73. Key: D Client Need: Safety and Infection Control
D. Sodium nitroprusside decreases blood pressure, which may result in patient dizziness when changing to a sitting or standing position.
A, B & C. These are acceptable nursing activities.
74. Key: B Client Need: Management of Care
B. Nurses are legally and ethically obligated to keep information about patients confidential. When health care professionals have reason to use records for data gathering, research or education, there is no break in confidentiality as long as the records are used with permission and according to established guidelines. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) gives consumers control over how their personal health information is used and limits the release of information without a patient’s consent.
A. The nurse does not have the authority to disclose confidential information about the patient’s condition to law enforcement personnel. Law enforcement personnel will have to obtain a subpoena to obtain this information through medical records.
C. Only by obtaining the patient’s permission can the nurse give information to others, including family members.
D. Only by obtaining the patient’s permission can the nurse give information to others, including the patient’s employer.
75. Key: D Client Need: Management of Care
D. The best approach for the nurse is to use calm, direct, assertive communication with the coworkers and to state that he/she would like to continue with the change of shift report.
A. By speaking in a louder voice, the nurse is not communicating directly and the nurse may be perceived as aggressive by the coworkers.
B. Waiting for the others to finish their discussion is non-assertive or passive behavior that results in delaying the nurse from beginning the shift and could impact patient safety.
C. A nurse should first communicate directly with the coworkers before asking the supervisor to intervene and sit in on the shift report.
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