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. The client covers electrical cords with a throw rug: This action is unsafe. Placing a throw rug over electrical cords poses a fire hazard and could lead to tripping. Electrical cords should be secured and kept out of walkways to prevent accidents.

B. The client set the water heater to 49 degrees Celsius (120 degrees Fahrenheit): The water heater should be set to a maximum temperature of 49°C (120°F) to prevent scalding injuries, which are a concern for older adults whose skin may be more sensitive. Temperatures higher than this increase the risk of burns.

C. The client has the refrigerator set to 7.2 degrees Celsius (45 degrees Fahrenheit): This temperature is too high. A refrigerator should be set at or below 4°C (40°F) to properly preserve food and prevent bacterial growth. Setting the refrigerator to 7.2°C (45°F) can result in foodborne illnesses.

D. The client has a standard height toilet seat in the bathroom: This may be inadequate for older adults, particularly those with mobility issues. A raised toilet seat may be recommended for better comfort and safety, as it reduces the risk of falls while sitting down or standing up.

A. Providing a 10 min rest period prior to meals B. Elevating the head of the client’s bed to 30 degrees during mealtime C. Instructing the client to place her chin toward her chest when swallowing D. Withholding fluids until the end of the meal

Correct Answer is C

Explanation

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

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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

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Explanation

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Correct Answer is C

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