A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?

B) Log the previous user out of the system:

The immediate action the nurse should take is to protect the client's confidentiality by logging out the previous user from the computer system. This ensures that unauthorized individuals do not have access to the client's health information. By taking this step promptly, the nurse mitigates the risk of unauthorized viewing of sensitive information.

A) Complete an incident report:

While completing an incident report is important for documenting the occurrence, it is not the first action the nurse should take. The priority is to address the immediate breach of confidentiality by securing the computer system to prevent further unauthorized access.

C) Report the incident to the charge nurse:

Reporting the incident to the charge nurse is essential, but it should follow the immediate action of logging out the previous user from the system. The charge nurse can then coordinate any necessary follow-up actions and ensure that appropriate measures are taken to prevent similar incidents in the future.

D) Offer to conduct a unit in-service on client confidentiality:

While staff education on client confidentiality is valuable for preventing future breaches, it is not the first action needed in response to the immediate situation. Addressing the current breach takes precedence to protect the client's privacy. Staff education can be considered as a proactive measure after addressing the immediate concern.

A) Recommend occupational therapy referral for the client: This is the priority action because the client is experiencing difficulty with activities of daily living (ADLs) due to left-sided weakness following a cerebrovascular accident. Occupational therapy focuses on improving the client's ability to perform ADLs and regain independence. Referring the client to occupational therapy is essential for maximizing functional ability and promoting recovery.

B) Reinforce teaching about the client's prescribed medications: While medication education is important for overall health management, it is not the priority in this situation. The client's immediate need is assistance with ADLs to address functional deficits resulting from the cerebrovascular accident.

C) Provide the client with a list of community resources: Community resources may be beneficial for the client's long-term care and support, but addressing the immediate need for assistance with ADLs takes precedence. Referring the client to occupational therapy will address the functional limitations more directly and effectively.

D) Encourage the client to discuss nutritional needs with a dietitian: Nutritional needs are important for overall health and recovery, but addressing the client's physical limitations and ADLs is the priority at this time. Once the client's ability to perform ADLs improves, discussions about nutrition can follow as part of a comprehensive care plan.