A charge nurse is observing the actions of the facility staff on the unit. Which of the following actions should the charge nurse identify as a possible legal issue?

A nurse does not provide an interpreter for a client who speaks a different language than the nurse.

A provider who suspects partner violence asks to speak with the client alone.

A dietitian prescribes a kosher meal tray for a client who practices the Orthodox Jewish faith.

A client requests that a nurse provide information by telephone to their partner.

Answer and Explanation

The Correct Answer is A

A. Not providing an interpreter for a client who speaks a different language may violate the client's right to understand their care, leading to potential legal issues regarding informed consent and patient safety.
B. A provider speaking to a client alone about suspected partner violence is appropriate as it ensures the client's privacy and safety during a sensitive discussion.
C. Prescribing a kosher meal tray for a client who practices the Orthodox Jewish faith is respectful and meets the dietary needs of the client, which is not a legal issue.
D. A client requesting that a nurse provide information to their partner is not inherently a legal issue, but the nurse must ensure that the client has consented to share their information to protect confidentiality.

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Correct Answer is A

Explanation

A. Logging the previous user out of the system immediately ensures the client's health information is no longer visible, protecting the client's privacy according to HIPAA guidelines.
B. Offering to conduct an in-service on client confidentiality is a proactive measure but does not address the immediate privacy issue.
C. Reporting the incident to the charge nurse is appropriate but does not prevent unauthorized viewing of the client's information immediately.
D. Completing an incident report is necessary to document the breach, but it should occur after protecting the client’s privacy by logging out.

A. A client who has dementia and is experiencing paranoia B. A client who has a UTI and reports itching after receiving a dose of cefaclor PO C. A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr D. A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III

Correct Answer is B

Explanation

A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.

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A charge nurse is observing the actions of the facility staff on the unit. Which of the following actions should the charge nurse identify as a possible legal issue?

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Naxlex Comprehensive Predictor Exams

A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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