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 a 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. Close the documentation program on the computer:

This action is appropriate as it immediately stops unauthorized access to the client's medical information and prevents further viewing of protected health information (PHI).

b. Find out which staff member left the documentation program on the screen:

While it's important to identify any staff member who may have left the documentation program open, addressing this issue should not be the first priority. The immediate concern is stopping the unauthorized access to the client's information and ensuring that the visitor is aware of the confidentiality breach.

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

Notifying the charge nurse about the incident is important, but it should not be the first action taken. The priority is to address the immediate breach of confidentiality and prevent further unauthorized access to the client's information.

d. Inform the visitor that client records are confidential:

This action may be appropriate after addressing the immediate breach of confidentiality. However, it should not be the first action taken as it does not immediately stop the unauthorized access to the client's information.

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Correct Answer is B

Explanation

a. MS 10 mg IV every 4 prn for pain

This choice is incorrect because it lacks clarity and proper formatting. "MS" could be misunderstood as "morphine sulfate," but it's not specified. Additionally, "every 4 prn for pain" is not a standard way to write a prescription. It should indicate the frequency (e.g., every 4 hours) and the indication for administration (e.g., prn for pain).

b. Morphine sulfate 10 mg IV q 4 hr IV prn for pain

This choice is the correct transcription of the prescription. It clearly states the medication (morphine sulfate), the dosage (10 mg), the route (IV), the frequency (every 4 hours), and the indication for administration (prn for pain).

c. MSO4 10 mg IVP q 4 prn for pain

This choice is incorrect due to the use of abbreviations that may not be universally understood. While "MSO4" likely stands for morphine sulfate, it's preferable to write it out completely to avoid confusion. Additionally, "q 4" is not clear and should be written as "every 4 hours."

d. Morphine sulfate 10.0 mg every 4 hours IV prn for pain

This choice is incorrect because it specifies the dosage with unnecessary precision (10.0 mg instead of 10 mg). While this level of precision is not typically required in medication prescriptions, it doesn't make the prescription incorrect per se. However, it's not the most common or standard way to write medication orders.

A. “The client is in the radiology department for a chest x-ray” B. “The client’s partner came to visit him 2 hours ago” C. “The client has routine vital signs prescribed” D. “The client is the president of a local bank”

Correct Answer is A

Explanation

a. “The client is in the radiology department for a chest x-ray.”

This information is relevant as it informs the oncoming nurse about the client's current location and the reason for the absence from the unit. It helps maintain awareness of the client's whereabouts and the ongoing diagnostic process.

b. “The client’s partner came to visit him 2 hrs. ago.”

While it's important to document visitor interactions in the client's chart, informing about a visit from 2 hours ago during a change-of-shift report may not be as pertinent to immediate patient care as other information. This detail can be communicated through other means, such as the client's chart or communication log.

c. “The client has routine vital signs prescribed.”is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.

d. “The client is the president of a local bank.”

While interesting, this information is not relevant to the client's current medical condition or care plan. It does not contribute to the immediate care needs of the client and can be considered extraneous during a change-of-shift report.

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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

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Correct Answer is A

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