A nurse enters the room of a client who is unconscious and finds that the client's son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first?
Recommend the son meet with the provider to get information about his mother's condition.
Complete an incident report regarding the breach of the client's confidentiality.
Log out the computer so that the client's son is unable to view his mother's information.
Report the possible violation of client confidentiality to the nurse manager.
The Correct Answer is C
Choice A reason: This is not the correct choice because recommending the son meet with the provider to get information about his mother's condition is not the first action the nurse should take. The nurse should first stop the unauthorized access to the client's records and protect the client's privacy and confidentiality. The nurse can then offer to arrange a meeting with the provider if the son has questions or concerns.
Choice B reason: This is not the correct choice because completing an incident report regarding the breach of the client's confidentiality is not the first action the nurse should take. The nurse should first intervene to prevent further disclosure of the client's information and secure the computer. The nurse can then document the incident and follow the facility's policy and procedure for reporting such events.
Choice C reason: This is the correct choice because logging out the computer so that the client's son is unable to view his mother's information is the first action the nurse should take. The nurse should act quickly and assertively to terminate the unauthorized access to the client's records and safeguard the client's rights. The nurse should also explain to the son why his action was inappropriate and how it violated the client's confidentiality.
Choice D reason: This is not the correct choice because reporting the possible violation of client confidentiality to the nurse manager is not the first action the nurse should take. The nurse should first address the immediate situation and ensure that the client's information is no longer accessible to the son. The nurse can then inform the nurse manager and the provider about the incident and the actions taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who requires discharge instructions for type 1 diabetes mellitus needs education on self-care, medication administration, blood glucose monitoring, diet, and exercise. These are complex tasks that require the knowledge and skills of a registered nurse.
Choice B reason: This is the correct choice because this assignment is appropriate for a licensed practical nurse. A client who is 1 day postoperative and has a continuous bladder irrigation needs routine care, such as vital signs, wound assessment, fluid intake and output, and catheter care. These are basic tasks that can be performed by a licensed practical nurse under the supervision of a registered nurse.
Choice C reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who requires a blood transfusion to be administered needs careful monitoring, such as checking for compatibility, verifying informed consent, observing for adverse reactions, and documenting the transfusion. These are advanced tasks that require the judgment and authority of a registered nurse.
Choice D reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who is receiving IV chemotherapy needs specialized care, such as preparing and administering the medication, managing side effects, providing emotional support, and following safety precautions. These are specialized tasks that require the training and certification of a registered nurse.
Correct Answer is B
Explanation
Choice A reason: Diminished hand-to-mouth coordination is not a finding that requires a referral to speech-language pathology, as it is related to the motor function of the upper extremities. The nurse should refer the client to physical therapy or occupational therapy for this issue.
Choice B reason: Impaired voluntary cough is a finding that requires a referral to speech-language pathology, as it indicates a possible dysfunction of the swallowing mechanism or the vocal cords. The nurse should refer the client to speech-language pathology for a swallowing evaluation and intervention.
Choice C reason: Altered level of consciousness is not a finding that requires a referral to speech-language pathology, as it is related to the neurological function of the brain. The nurse should monitor the client's Glasgow Coma Scale score and report any changes to the provider.
Choice D reason: Unilateral ptosis is not a finding that requires a referral to speech-language pathology, as it is related to the cranial nerve function of the eye. The nurse should assess the client's pupillary response and eye movements and report any abnormalities to the provider.
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