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

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

Discarding worksheets containing client information in a wastebasket.

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

Choice A rationale: Writing a client's diagnosis on the message board in the client's room can expose sensitive information to anyone who enters the room, which compromises client confidentiality.

Choice B rationale: Discarding worksheets containing client information in a wastebasket is not secure and can lead to unauthorized access to confidential information.

Choice C rationale: Giving change-of-shift report to a nurse outside the client's room protects client confidentiality by ensuring that sensitive information is shared only with authorized personnel in a private setting.

Choice D rationale: 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

Choice A rationale:

Evaluating the client for signs of infection is an important nursing action in post-procedure care, but it is not the priority immediately following an amniotomy. The primary concern after an amniotomy is fetal well-being, so monitoring the fetal heart rate is the priority.

Choice B rationale:

Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. Amniotomy involves breaking the amniotic sac, which can potentially lead to changes in the fetal heart rate. Monitoring the fetal heart rate helps assess the baby's well-being and detects any signs of fetal distress.

Choice C rationale:

Observing the color and consistency of amniotic fluid is important for assessing the fluid for signs of meconium staining or infection, but it is not the immediate priority after an amniotomy. Checking the fetal heart rate takes precedence.

Choice D rationale:

Taking the client's temperature is an important part of assessing for infection or fever, but it is not the immediate priority following an amniotomy. Fetal well-being and monitoring are the primary concerns in the immediate post-amniotomy period.

A. Provider's progress notes. B. Controlled substance inventory record. C. Incident report. D. Nursing care plan.

Correct Answer is C

Explanation

Choice A rationale:

Documenting the medication error in the provider's progress notes is not the appropriate location for documenting a medication error. Progress notes are typically used to record the client's clinical progress and assessments, not incidents of medication errors.

Choice B rationale:

The controlled substance inventory record is used to track the dispensing and administration of controlled substances in a healthcare facility. Documenting a medication error in this record is not appropriate, as it is not the purpose of this document.

Choice C rationale:

Documenting the medication error in an incident report is the correct action. Incident reports are used to document and track adverse events or errors that occur in healthcare settings. This allows for proper investigation, analysis, and the implementation of preventive measures to avoid similar errors in the future.

Choice D rationale:

The nursing care plan is a document that outlines the client's nursing care needs, goals, and interventions. While it may include information about medication administration, it is not the appropriate place to document a medication error. An incident report is specifically designed for this purpose and ensures that the error is appropriately addressed and investigated.

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

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is to undergo an amniotomy.Which of the following is the priority nursing action following this procedure?

Correct Answer is B

Explanation

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain.The nurse inadvertently administers 2 tablets to the client.In which of the following locations should the nurse document this client care incident?

Correct Answer is C

Explanation

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