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.)

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

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

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

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

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

Answer and Explanation

Correct Answer : C,E

A. Reviewing an electronic list of admitted clients is not a breach of confidentiality as long as the nurse has a legitimate reason for accessing the information for patient care purposes.

B. Logging out of the computer before leaving the workstation demonstrates proper protection of electronic health information and is not a breach.

C. Discussing a client’s condition in a public area where a visitor can overhear constitutes a breach of confidentiality because private health information is exposed to unauthorized individuals.

D. Faxing data to a referred provider is appropriate if done securely and only to the intended recipient as part of care coordination. It does not breach confidentiality.

E. Informing a friend of the client’s condition is a clear breach of confidentiality because health information is being shared with someone who is not authorized to receive it.

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Correct Answer is C

Explanation

A. Clients with paraplegia are at risk for constipation due to decreased mobility. A low-fiber diet would worsen bowel issues. A high-fiber diet with adequate fluids is typically recommended to maintain regular bowel function.

B. Clients with paraplegia are not contraindicated for the influenza vaccine; in fact, vaccination is important to prevent respiratory infections, which can be more serious in individuals with limited mobility.

C. Instructing the client to empty their bladder every 2 hours helps prevent urinary retention and reduces the risk of urinary tract infections, which are common complications in clients with paraplegia due to impaired bladder function.

D. Instructing the client to change positions every 3 hours when sitting in a chair is insufficient for pressure injury prevention. Clients should be encouraged to shift weight every 15–30 minutes and reposition regularly to prevent skin breakdown.

A. The AP removes cut flowers from the room of a client who is in a protective environment. B. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile. C. The AP wears a mask when caring for a client who has varicella. D. The AP closes the door of a client who is on airborne precautions.

Correct Answer is B

Explanation

A. Removing cut flowers from a protective environment is appropriate because fresh flowers can harbor pathogens, which poses a risk to immunocompromised clients.

B. Using alcohol-based hand antiseptic after caring for a client with Clostridium difficile is ineffective, as alcohol does not kill C. difficile spores. Proper hand hygiene requires soap and water, so this action requires correction and education.

C. Wearing a mask when caring for a client with varicella (chickenpox) is correct because varicella is transmitted via airborne particles, and appropriate personal protective equipment reduces infection risk.

D. Closing the door for a client on airborne precautions is correct and helps prevent the spread of airborne pathogens to other areas of the facility.

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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

A nurse in a rehabilitation facility is preparing a discharge plan for a client who has paraplegia. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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