A charge nurse is walking outside on the facility's grounds during break time and overhears two nurses discussing the biopsy results of a client who is on the unit. Which of the following actions should the nurse take? (Select all that apply.)

Tell the nurses to lower their voices when discussing a client.

Plan an in-service program for the nurses about HIPAA privacy rules,

Ask the nurses to stop discussing the client's protected health information.

Inform the nurse manager about the confidentiality breach.

Complete an incident report about the nurses' breach of confidentiality.

Answer and Explanation

Correct Answer : B,C,D,E

Rationale:

A. This option is incorrect because merely telling the nurses to lower their voices does not address the underlying violation of HIPAA regulations. Protected health information (PHI) should not be discussed in public areas at all, regardless of voice volume.

B. This option is correct because planning an in-service program about HIPAA privacy rules helps educate staff and prevent future breaches of confidentiality. Ongoing staff education reinforces the importance of protecting client information.

C. This option is correct because asking the nurses to stop discussing the client’s PHI immediately addresses the current violation and prevents further unauthorized disclosure. This is an appropriate and immediate intervention to protect client privacy.

D. This option is correct because informing the nurse manager ensures that leadership is aware of the confidentiality breach. The manager can provide guidance, implement corrective action, and ensure compliance with facility policy and legal requirements.

E. This option is correct because completing an incident report documents the breach formally. Incident reports help track violations, facilitate follow-up, and ensure accountability, which is essential for maintaining HIPAA compliance and protecting client privacy.

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Correct Answer is A

Explanation

Rationale:

A. This option is correct because measuring and recording a client’s urinary output is within the scope of practice for an assistive personnel (AP). This task is noninvasive, routine, and does not require nursing judgment, making it appropriate for delegation.

B. This option is incorrect because performing a sterile dressing change is a nursing intervention that requires knowledge of aseptic technique, assessment skills, and clinical judgment. It cannot be delegated to an AP.

C. This option is incorrect because instructing a client on the use of crutches involves teaching, assessment of the client’s abilities, and evaluation of safety, all of which are nursing responsibilities and cannot be delegated to an AP.

D. This option is incorrect because interpreting an ECG strip requires specialized nursing knowledge and clinical judgment to identify dysrhythmias and respond appropriately. This is outside the AP’s scope of practice.

A. A client who is comatose due to severe head trauma B. A client who has a compound fracture of the right forearm C. A client who has a severed lower extremity D. A client who has multiple abrasions

Correct Answer is C

Explanation

Rationale:

A. This option is incorrect because a comatose client with severe head trauma may have a poor prognosis and is considered expectant in a mass casualty scenario. Resources are typically allocated to clients with a higher likelihood of survival.

B. This option is incorrect because a compound fracture of the forearm is serious but not immediately life-threatening. This client can safely wait for treatment without the risk of rapid deterioration.

C. This option is correct because a client with a severed lower extremity is at high risk for hemorrhagic shock and requires immediate intervention to control bleeding and stabilize the patient. In mass casualty triage, clients with life-threatening but potentially survivable injuries are prioritized for transport to acute care facilities.

D. This option is incorrect because multiple abrasions are minor injuries that are not life-threatening. These clients are considered "green tag" or walking wounded and are the lowest priority for immediate transport.

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A charge nurse is walking outside on the facility's grounds during break time and overhears two nurses discussing the biopsy results of a client who is on the unit. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

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Correct Answer is A

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Correct Answer is C

Explanation

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