A nurse enters the hallway and discovers a visitor looking at a client’s medical information on a computer. Which of the following actions should the nurse take first?

Close the documentation program on the computer

Find out which staff member left the documentation program on the screen

Tell the charge nurse that the visitor viewed a client’s protected health information

Inform the visitor that client records are confidential

Answer and Explanation

The Correct Answer is A

A. Closing the documentation program on the computer is the most immediate action to prevent further unauthorized access to protected health information (PHI). It directly addresses the breach of confidentiality and limits potential damage.

B. While it is important to identify the staff member responsible for leaving the program open, this does not immediately address the current breach of confidentiality. This action would be a subsequent step after securing the PHI.

C. Notifying the charge nurse is an important step in the process of addressing the breach. However, it is not the first action to take as it does not prevent further exposure of the PHI.

D. Informing the visitor about the confidentiality of client records is necessary, but it is not the first action to take. The priority is to secure the PHI before addressing the visitor's behavior.

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Correct Answer is A

Explanation

a. Cutaneous anthrax is typically treated with antibiotics, so preparing to administer antibiotics to the client is the appropriate action.
b. While respiratory protection may be necessary in certain situations, such as when dealing with airborne pathogens, anthrax exposure typically does not require an N95 respirator mask.
c. Anthrax is caused by a bacterium, not a virus, so administering an antiviral medication would not be effective in treating the infection.
d. Placing a surgical mask on the client during transfer may not be necessary unless there are specific concerns about the spread of respiratory droplets. However, the primary treatment for cutaneous anthrax is antibiotics, not respiratory precautions.

A. Review the chart for nonrestraint alternatives for agitation B. Inform the unit manager C. Speak with the AP about the incident D. Remove the restraints from the client’s wrist

Correct Answer is D

Explanation

a. Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b. Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c. Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d. Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.

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A nurse enters the hallway and discovers a visitor looking at a client’s medical information on a computer. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A charge nurse making rounds observes that assistive personnel has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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