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 ["A","C"]

Explanation

A. If the client requires supplemental oxygen, an oxygen tank may be necessary. Clients with tracheostomies might need supplemental oxygen depending on their underlying condition and oxygenation needs. However, not all tracheostomy patients will require an oxygen tank, so this depends on the specific medical situation of the client.
B. Pipe cleaners are not a standard supply for tracheostomy care. They are not recommended for cleaning the tracheostomy tube or the stoma. Instead, tracheostomy care usually involves cleaning with specific, approved cleaning supplies and techniques, such as sterile saline or tracheostomy care kits.
C. The obturator is a crucial tool used in the initial placement of a tracheostomy tube. It helps guide the tube into place. While not always needed on a daily basis, the obturator should be kept accessible in case the tracheostomy tube needs to be replaced or if the tube becomes dislodged. It is important for emergency situations to have an obturator available.
D. Cotton balls are not recommended for tracheostomy care because they can shed fibers that may cause irritation or potential obstruction in the tracheostomy tube. Instead, sterile gauze or other appropriate dressing materials are used to manage the area around the tracheostomy.
E. Petroleum jelly should not be used around the tracheostomy stoma or on the tracheostomy tube. It can cause a buildup of residue, potentially leading to irritation or infection. It is important to use only recommended products and techniques for tracheostomy care, such as sterile saline or appropriate tracheostomy care products.

A. Ask the nurse manager who should perform the task. B. Perform the oral care. C. Ask a licensed practical nurse to perform the task. D. Check the AP job description.

Correct Answer is D

Explanation

A. While consulting with the nurse manager is appropriate in some cases, it's important to first verify the AP's scope of practice.
B. If the AP is not qualified to perform the task, the nurse may need to perform it themselves or delegate it to someone who is qualified. However, it's important to first verify the AP's scope of practice to avoid unnecessary delegation.
C. This may be a viable option if the AP is not qualified to perform the task and the nurse is unable to do it themselves. However, it's important to ensure that the licensed practical nurse has the necessary training and competence to perform the task safely and effectively.
D. The AP job description outlines the specific tasks and responsibilities that the AP is authorized to perform. By checking the job description, the nurse can determine if the AP is indeed qualified to perform oral care for an unconscious client.

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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

A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

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Correct Answer is D

Explanation

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