A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

An assistive personnel is informing a friend of the client about their condition.

A nurse and a provider are discussing a client's condition at the nurses' station while a visitor is present.

An assistive personnel logs out of the computer prior to responding to a call light.

A nurse is faxing data about a client to a preferred provider.

A nurse is reviewing an electronic list of all clients admitted to the unit.

Answer and Explanation

Correct Answer : A,B,E

A. This is a clear breach of confidentiality as sharing client information with individuals who are not part of the healthcare team and without the client's consent violates patient privacy.

B. Discussing a client’s condition in a public area where unauthorized individuals (like visitors) can overhear is a breach of confidentiality. Patient information should be discussed in private settings to protect the client's privacy.

C. This action is a good practice to protect patient information and does not breach confidentiality.

D. This is acceptable as long as proper protocols are followed, such as using secure fax lines and confirming that the receiving party is authorized to receive the information. This action does not inherently breach confidentiality.

E. If the nurse is not involved in the care of all those clients and does not have a legitimate reason to access that information, this action can also be considered a breach of confidentiality. Healthcare providers should only access information relevant to their role and responsibilities.

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Correct Answer is C

Explanation

Choice A Reason:
The time the client received his last dose of pain medication is incorrect. While this information is relevant for ongoing pain management, it may not be as critical for the receiving facility unless there are specific pain management protocols in place that need to be followed.
Choice B Reason:
The client's preferred time for bathing is incorrect. While knowing the client's preferences is important for providing individualized care, the preferred time for bathing may not be immediately pertinent to the client's care upon transfer to the rehabilitation facility.
Choice C Reason:
The steps to follow when providing wound care is correct. This information is essential for the receiving facility to ensure proper wound care continues without interruption. It helps ensure consistency in care and minimizes the risk of complications related to wound healing.
Choice D Reason:
The belief that the client has a difficult relationship with his son is incorrect. While psychosocial information about the client is important for holistic care, it may not be the most crucial information to include in the change-of-shift report for transfer to a rehabilitation facility unless it directly impacts the client's medical care or rehabilitation plan.

A. Providing written information to a client regarding palliative care B. Documenting a client's refusal to take a prescribed medication C. Obtaining an interpreter for a client who speaks a different language than the nurse D. Initiating IV access on a client who has dementia while he is sleeping E. Implementing a client's plan of care based upon nursing goals

Correct Answer is ["A","C"]

Explanation

Choice A Reason:
Providing written information to a client regarding palliative care is correct. Advocating for the client's autonomy and right to information by providing written materials about palliative care empowers the client to make informed decisions about their care.
Choice B Reason:
Documenting a client's refusal to take a prescribed medication is incorrect. While documenting a client's refusal is important for accurate medical records, it is not an example of advocacy. Advocacy involves actively supporting the client's rights, preferences, and needs.
Choice C Reason:
Obtaining an interpreter for a client who speaks a different language than the nurse is correct. Advocating for effective communication ensures that the client can fully understand and participate in their care, regardless of language barriers. Obtaining an interpreter facilitates communication and promotes the client's right to understand and be understood.
Choice D Reason:
Initiating IV access on a client who has dementia while he is sleeping is incorrect. This scenario raises ethical concerns as it involves performing a procedure on a client who is unable to provide consent due to being asleep and having dementia. Without explicit consent or a medical emergency necessitating immediate intervention, initiating IV access in this situation may not align with client advocacy principles.
Choice E Reason:
Implementing a client's plan of care based upon nursing goals is incorrect. While implementing a client's plan of care is part of the nurse's role, it is not necessarily an example of advocacy. Advocacy involves actively promoting and safeguarding the client's rights, preferences, and well-being, which may sometimes involve advocating for modifications to the plan of care based on the client's needs and goals.

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A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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a

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