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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E"}
Explanation
The nurse should prepare to administer naloxone and oxygen by face mask 10 L/min.
Rationale:
- Naloxone is used to reverse opioid-induced respiratory depression, which is a potential risk during moderate sedation.
- Oxygen by face mask 10 L/min is necessary to maintain adequate oxygenation during and after sedation, as respiratory depression can occur.
- Acetaminophen is not used for immediate management of sedation-related complications.
- An additional dose of fentanyl or propofol would deepen sedation, not manage its complications.
- Propranolol is a beta-blocker that is not indicated in this situation.
Correct Answer is A
Explanation
A. Small clots with tissue in the urine. It is expected for a client 2 days post-TURP to have small clots and tissue debris in the urine as part of the healing process. Continuous bladder irrigation (CBI) often helps clear these.
B. Dark red urine. Bright red or dark red urine can indicate active bleeding, which is not expected 2 days post-op and requires immediate intervention.
C. Urinary output 25 mL/hr. This is too low (normal output should be at least 30 mL/hr) and could indicate catheter blockage, dehydration, or renal impairment, which is not expected.
D. Pain of 8 on a scale of 0 to 10. Mild discomfort is expected, but severe pain (8/10) is abnormal and could indicate bladder spasms, catheter blockage, or another complication requiring intervention.
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