A nurse observes two assistive personnel (AP) discussing a client's information in the facility cafeteria. Which of the following actions should the nurse take?

Remind the AP about maintaining client confidentiality.

Notify the client of the breach of confidentiality.

Notify the ethics committee of the breach of confidentiality.

File an incident report with the risk management department.

Answer and Explanation

The Correct Answer is A

A. Reminding the AP about confidentiality is the appropriate immediate response. The nurse should provide education and reinforce HIPAA regulations to prevent future breaches.
B. Notifying the client is unnecessary and could cause undue distress. The priority is to address the behavior and prevent further violations.
C. Notifying the ethics committee is excessive for a first-time or minor violation. This step may be necessary if breaches continue despite education.
D. Filing an incident report is not required unless the breach has significant consequences. The best first step is direct education.

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Correct Answer is ["B","C","E"]

Explanation

A. Insert an NG tube for a client who requires enteral feedings. This is incorrect because inserting an NG tube requires assessment and skill beyond the scope of practice of assistive personnel. This task should be performed by a nurse.
B. Record a client's intake after each meal. This is correct because recording intake is a non-clinical task within the scope of an assistive personnel’s role.
C. Obtain a client's vital signs every 4 hr. This is correct because measuring and documenting vital signs is a standard duty that assistive personnel can perform.
D. Instruct a client on the use of an incentive spirometer. This is incorrect because client education is a nursing responsibility and cannot be delegated to assistive personnel.
E. Transfer a client to physical therapy. This is correct because assistive personnel can safely assist with client transfers as long as no clinical judgment is required.

A. Polyuria B. Fever C. Diarrhea D. Diaphoresis

Correct Answer is B

Explanation

A. Polyuria. Increased urination is not a common adverse effect of clozapine and does not require immediate reporting.
B. Fever. Clozapine can cause agranulocytosis, a serious condition that suppresses white blood cell production. Fever may indicate infection, which requires immediate evaluation.
C. Diarrhea. Gastrointestinal symptoms can occur with clozapine but are not typically urgent unless severe or persistent.
D. Diaphoresis. Excessive sweating is a possible side effect but does not require immediate medical attention.

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A nurse observes two assistive personnel (AP) discussing a client's information in the facility cafeteria. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

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