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 []
Explanation
Potential Condition: Opioid intoxication
Actions to Take:
- Obtain a prescription for naloxone
- Prepare to initiate mechanical ventilation
Parameters to Monitor:
- Pupillary reaction,
- Respiratory rate
Rationale:
- Potential Condition: The client presents with shallow breathing, slurred speech, confusion, pupillary constriction, and bradycardia, which are classic signs of opioid intoxication. The history of back pain also suggests possible opioid use.
- Actions to Take:
- Naloxone is an opioid antagonist that can rapidly reverse respiratory depression caused by opioid overdose.
- Mechanical ventilation may be necessary if respiratory depression is severe and does not improve with naloxone administration.
- Parameters to Monitor:
- Pupillary reaction is important because opioids cause pupillary constriction (miosis). Improvement in pupillary size and reaction indicates the opioid effects are wearing off.
- Respiratory rate should be closely monitored since opioid overdose primarily affects respiratory drive, leading to hypoxia and potential respiratory failure.
Correct Answer is C
Explanation
A. Apply restraints if the client is agitated. Restraints are not necessary and may increase distress. Post-seizure agitation should be managed with reassurance and monitoring.
B. Ambulate the client. This is unsafe because the client may be disoriented or weak, increasing the risk of falls. Rest and recovery should be prioritized.
C. Position the client on their side. This helps maintain an open airway, prevents aspiration, and facilitates secretion drainage, making it the priority intervention.
D. Raise all of the side rails on the client's bed. Raising all four side rails is considered a restraint. A safer environment should be maintained without unnecessary restriction.
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