A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.

Discarding worksheets containing client information in a wastebasket

Writing a client's diagnosis on the message board in the client's room

Giving change of shift report to a nurse outside the client's room

Discussing a client's prognosis with an assistive personnel who is caring for the client

Answer and Explanation

The Correct Answer is C

A. Discarding worksheets containing client information in a wastebasket does not ensure proper disposal of confidential information and could compromise confidentiality.
B. Writing a client's diagnosis on the message board in the client's room could breach confidentiality, as it could potentially be seen by unauthorized individuals.
C. This action protects client confidentiality because it involves discussing sensitive information in a private setting where unauthorized individuals are less likely to overhear. This is an appropriate method of communicating client information during a handoff.
D. While sharing relevant information with personnel directly involved in the client's care is generally acceptable, it must still be done in a manner that safeguards confidentiality.

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Correct Answer is B

Explanation

A.Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs.

B.It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary.

C.Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use.

D.The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.

A. Administer aspirin if the client develops a fever. B. Initiate contact precautions for the client. C. Assign the client to a negative-pressure airflow room. D. Have visitors remain at least 0.91 m (3 feet. away from the client.

Correct Answer is C

Explanation

The correct answer is choicec. Assign the client to a negative-pressure airflow room.

Choice A rationale:

Administering aspirin to a client with varicella zoster is not recommended due to the risk of Reye’s syndrome, a serious condition that can cause swelling in the liver and brain.

Choice B rationale:

While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.

Choice C rationale:

Assigning the client to a negative-pressure airflow room is crucial because it helps contain the airborne virus and prevents it from spreading to other areas of the hospital.

Choice D rationale:

Having visitors remain at least 0.91 m (3 feet) away from the client is a good practice, but it is not sufficient on its own to prevent the spread of the virus. Airborne precautions, including a negative-pressure room, are necessary.

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A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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