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

Instruct the AP to discontinue the conversation.

Notify the client's provider about the incident.

Reassign the AP to other clients on the unit.

Complete an incident report about the breach of client confidentiality

Answer and Explanation

The Correct Answer is D

A.   By instructing the AP to stop discussing the client's care in a public area, the nurse helps prevent further exposure of sensitive information. However, while this step is necessary to immediately correct the behavior, it is not sufficient on its own to address the breach thoroughly.
B.   This action is not appropriate as the primary responsibility for addressing a breach of confidentiality falls within the scope of nursing management and organizational policies, rather than the client's provider.
C.   Reassigning the AP does not address the issue of confidentiality. The priority is to correct the behavior and ensure that such breaches do not occur in the future. Reassignment would not resolve the confidentiality breach or prevent further incidents.
D.   This action is appropriate because it provides a formal mechanism to document the breach of confidentiality. Completing an incident report ensures that the issue is recorded and can be reviewed by management to address the breach and prevent future occurrences.

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Correct Answer is D

Explanation

A. This is a standard intervention for phototherapy, as it helps to protect the eyes from excessive light exposure.
B. Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago. This is a necessary intervention to monitor for potential complications, such as compartment syndrome, after a cast is applied.
C. Administer a bronchodilator two times a day for child who has cystic fibrosis. This is a common treatment for cystic fibrosis, as bronchodilators help to open the airways and improve breathing.
D. This is an inflammatory bowel disease characterized by inflammation of the large intestine. During an exacerbation, the goal is to reduce inflammation and promote healing. While a low-fiber diet may be helpful during an acute exacerbation to reduce bowel irritation, a high-protein diet is not recommended.

A. Instruct the newly licensed nurse to complete an incident report. B. Document the incident in the client's medical record. C. Provide the client with information about the incident. D. Communicate the incident to the nurse manager.

Correct Answer is D

Explanation

A. While completing an incident report is important for documenting the event, the witness should not instruct the newly licensed nurse to do so. Instead, it is the responsibility of the observer (the witness nurse) to report the incident to the appropriate authority to ensure that it is addressed properly.
B. Documenting the incident in the client's medical record is not appropriate in this case. The client’s medical record should only contain information relevant to the client’s care and treatment, not details about medication errors or policy violations.
C. While transparency is important, directly informing the client about a medication error is not typically the responsibility of the witnessing nurse. The primary focus should be on addressing the immediate issue and ensuring it is reported to the appropriate authorities rather than discussing the incident with the client.
D. The nurse manager is responsible for overseeing the unit and addressing incidents such as medication errors. Reporting the incident to the nurse manager ensures that it is investigated according to facility protocols.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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