A nurse overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?
Reassign the AP to other clients on the unit
Instruct the AP to discontinue the conversation
Complete an incident report about the breach of client confidentiality
Notify the client's provider about the incident
The Correct Answer is B
Choice A reason: Reassigning the AP to other clients on the unit is not an appropriate action for the nurse to take. This action does not address the issue of the breach of client confidentiality, and it may disrupt the continuity of care for the clients. The nurse should not punish the AP without giving them feedback and education.
Choice B reason: Instructing the AP to discontinue the conversation is an appropriate action for the nurse to take. This action stops the violation of client confidentiality and protects the client's privacy and dignity. The nurse should also remind the AP of the ethical and legal principles of confidentiality, and the consequences of violating them.
Choice C reason: Completing an incident report about the breach of client confidentiality is not an appropriate action for the nurse to take. This action is not necessary, as the breach was not intentional or harmful to the client. The nurse should document the incident in the AP's performance evaluation, and provide guidance and coaching to prevent future occurrences.
Choice D reason: Notifying the client's provider about the incident is not an appropriate action for the nurse to take. This action is not relevant, as the provider is not responsible for the AP's behavior or education. The nurse should notify the AP's supervisor or manager, and collaborate with them to address the issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Calling the provider if you note clubbing of the client's fingernails is not an instruction the charge nurse should include in the teaching. This is an unnecessary and inappropriate action, as clubbing is a chronic and irreversible sign of hypoxia that does not require immediate intervention. The nurse should document the finding and monitor the client's respiratory status.
Choice B reason: Having an assistive personnel ambulate the client just before meals is not an instruction the charge nurse should include in the teaching. This is a harmful and contraindicated action, as ambulation can increase the client's oxygen demand and cause dyspnea and fatigue. The nurse should schedule the client's activity and rest periods around the meals and provide supplemental oxygen as prescribed.
Choice C reason: Notifying the charge nurse if you observe that the client has distended neck veins is an instruction the charge nurse should include in the teaching. This is a necessary and appropriate action, as distended neck veins can indicate right-sided heart failure, which is a complication of COPD. The nurse should report the finding and assess the client for other signs of fluid overload, such as edema, weight gain, and crackles.
Choice D reason: Maintaining the client's oxygen saturation level above 95 percent is not an instruction the charge nurse should include in the teaching. This is an unrealistic and potentially harmful goal, as clients with COPD usually have lower oxygen saturation levels due to chronic hypoxia. The nurse should maintain the client's oxygen saturation level at the prescribed range, which is typically between 88 and 92 percent.
Correct Answer is B
Explanation
A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.
B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.
C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.
D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.
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