A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr.

Which of the following interventions should the nurse anticipate?

The correct answer is b. Remove the device from the room.

Choice A rationale:

• Reporting the defect to the equipment maintenance staff is essential,but it's not the immediate priority.The primary concern is to eliminate the safety hazard posed by the frayed cord to prevent potential harm to the client and others.
• Delaying the removal of the device could lead to electrical shock,fire,or other serious consequences.
• Therefore,removing the device from the room takes precedence over reporting the defect.

Choice B rationale:

• Removing the device from the room is the most appropriate first action because it:
  • Eliminates the immediate safety hazard.
  • Prevents potential harm to the client and others.
  • Protects the device from further damage.
  • Ensures the safety of the environment.
  • Demonstrates the nurse's prioritization of patient safety.

Choice C rationale:

• Initiating a requisition for a replacement CPM device is necessary to ensure the client's continued treatment.
• However,it's not the first action because it doesn't address the immediate safety concern.
• The nurse should first remove the faulty device and then initiate the process for obtaining a replacement.

Choice D rationale:

• Ensuring the device inspection sticker is current is a vital part of equipment maintenance.
• However,it's not relevant to the immediate safety issue of the frayed cord.
• The presence of a current inspection sticker doesn't guarantee the device's safety or functionality at that moment.
• The nurse must prioritize removing the hazard and then follow up with appropriate documentation and reporting.

The correct answer is choice D. The nurse should include that information technology will install a firewall to secure client information.

A firewall is a system that protects the network from unauthorized access and prevents data breaches. A firewall is essential for ensuring the confidentiality, integrity, and availability of electronic health records .

Choice A is wrong because the nurse should change their password more frequently than once per year. Changing passwords regularly reduces the risk of unauthorized access and enhances security .

Choice B is wrong because the documentation of sensitive material is not performed by the charge nurse. The nurse who provides the care should document it accurately and promptly in the computerized system .

Choice C is wrong because the nurse will not be given access to the medical records of every client in the facility. The nurse should only access the records of the clients they are assigned to care for, following the principle of need-to-know .