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 A

Explanation

a. Institute rounds every 2 hr. during the day to offer toileting:

This intervention is appropriate as it helps address the need for toileting assistance, which can reduce the risk of falls associated with residents attempting to ambulate to the bathroom independently. Regular toileting rounds can help prevent falls related to toileting urgency or difficulty.

b. Apply vest restraints on the residents who are confused:

Using restraints, such as vest restraints, should be avoided whenever possible due to the increased risk of physical and psychological harm to residents. Restraints do not address the underlying causes of falls and can contribute to agitation, loss of mobility, and pressure injuries.

c. Accompany residents older than 85 years of age during ambulation:

This intervention is appropriate, especially for residents who are at increased risk of falls, such as those over 85 years of age. Accompanying residents during ambulation allows for assistance and support, reduces the risk of falls, and provides an opportunity for early intervention if balance or mobility issues arise.

d. Keep four side rails up on the beds at night:

Keeping all four side rails up on the beds can increase the risk of entrapment and may not be necessary for all residents. Using bed rails should be individualized based on each resident's risk assessment and should follow facility policies and guidelines to prevent entrapment and ensure resident safety.

A. Limited social support B. Decreased self-esteem C. Inadequate food supply D. Low pain tolerance

Correct Answer is C

Explanation

a. Limited social support:

Limited social support can impact the client's ability to manage their recovery and may increase the risk of complications or readmission. However, it may not be the most immediate concern if other issues pose a more significant risk to the client's health and recovery.

b. Decreased self-esteem:

Decreased self-esteem can affect the client's emotional well-being and may impact their motivation to engage in self-care activities. While important to address, it may not have an immediate impact on the client's physical recovery following CABG surgery.

c. Inadequate food supply:

Inadequate food supply can hinder the client's ability to meet their nutritional needs, which are essential for wound healing and overall recovery after surgery. This issue could potentially impact the client's physical recovery and should be addressed promptly.

d. Low pain tolerance:

Low pain tolerance can affect the client's ability to manage postoperative pain and may hinder their participation in activities necessary for recovery, such as mobility and respiratory exercises. Addressing pain management is crucial for promoting the client's comfort and facilitating recovery.

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