A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
Complete an incident report about the breach of confidentiality.
Tell the nurse that permission from the risk manager is required to view the client's record.
Remind the nurse that only staff caring for the client may access the client's record.
Contact facility security to remove the nurse from the unit.
The Correct Answer is C
A. Completing an incident report about the breach of confidentiality may be necessary, but it
should not be the first action. The immediate concern is addressing the behavior and reminding the nurse of proper protocol.
B. While it may be true that permission from the risk manager is required to access certain
records, this response does not address the immediate issue of the unauthorized access. It's more important to address the behavior directly.
C. This is the most appropriate action because it directly addresses the unauthorized access to the client's medical record. Reminding the nurse of the proper protocol for accessing medical records can help prevent further breaches of confidentiality.
D. Contacting facility security to remove the nurse from the unit may be excessive at this stage and should be considered if the behavior persists after reminders about proper protocol.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Applying restraints over clothing helps to prevent direct skin contact, which can reduce the risk of skin irritation, abrasions, and pressure sores that might occur from prolonged contact with the restraint material. It also serves as a layer of padding, offering additional comfort for the patient. Moreover, clothing can act as a barrier against potential constriction of blood flow or nerve compression.
B. Two fingers should fit between the restraint and the client's body and not four fingers. This helps prevent excessive tightness, which can lead to restricted circulation and skin breakdown. This action promotes client safety and comfort.
C. Checking the client's skin integrity should be done done more frequently than the four hours to assess for any skin damage or irritation.
D. Tying the belt restraint to the side rail of the bed may pose a safety risk, as it could restrict the client's movement and lead to injury or discomfort. The belt restraint should be anchored to an immobile part of the bed.
Correct Answer is B
Explanation
A. Limiting snacks between meals may further decrease the client's overall food intake, which could exacerbate the risk of malnutrition.
B. Providing the client with finger foods makes eating more manageable for individuals with dementia who may have difficulty using utensils or maintaining attention during meals. This approach encourages independent eating and may increase food intake.
C. Restricting visitors during meals may lead to social isolation and could interfere with the client's enjoyment of mealtime, potentially further reducing food intake.
D. Providing the client with three large meals each day may be overwhelming and may not align with the client's preferences or eating habits. Offering smaller, more frequent meals throughout
the day is often more manageable for individuals with dementia.
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