A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?
"Do you understand HIPAA regulations?"
"This discussion is only appropriate in a private area."
"Please stop this discussion."
"Did you know you can be liable if you breach confidentiality?"
The Correct Answer is C
A. While understanding HIPAA regulations is important, addressing the immediate inappropriate behavior takes precedence.
B. While directing the conversation to a private area is appropriate, stopping the discussion immediately is the priority.
C. The priority is to stop the discussion immediately to prevent further breach of confidentiality.
D. While informing about potential liability for breaching confidentiality is important, addressing the immediate behavior is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The water seal chamber should contain at least 2 cm of water to maintain the seal and prevent air from entering the pleural space. Only 1 cm of water is inadequate and requires intervention.
B. Tidaling, or fluctuation of water with respirations, is an expected finding and indicates that the system is functioning properly.
C. A suction chamber pressure of -20 cm H₂O is the standard setting for chest tube drainage systems and does not require intervention.
D. A drainage collection chamber that is one-third full is within normal limits and simply indicates the need to continue monitoring output.
Correct Answer is B
Explanation
A. While a blood pressure of 156/90 mm Hg may be elevated, it is not necessarily an indication to withhold propranolol, which is commonly used to treat hypertension.
B. A pulse rate of 54/min suggests bradycardia, which is a potential side effect of propranolol and may warrant withholding the medication.
C. A potassium level of 5.2 mEq/L is within the normal range (3.5-5.0 mEq/L) and is not typically a reason to withhold propranolol.
D. A sodium level of 130 mEq/L is within the normal range (135-145 mEq/L) and is not typically a reason to withhold propranolol.
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