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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: A client who has a displaced femur fracture from a fall is a priority client, but not the highest priority. The nurse should assess the client for signs of bleeding, infection, nerve damage, and compartment syndrome, and provide pain relief and immobilization. However, the client's condition is not as urgent or life-threatening as the other clients.

Choice B reason: A client who is experiencing severe vomiting and diarrhea with tachycardia is a priority client, but not the highest priority. The nurse should assess the client for signs of dehydration, electrolyte imbalance, and shock, and provide fluid and electrolyte replacement and antiemetic medication. However, the client's condition is not as urgent or life-threatening as the other clients.

Choice C reason: A client who is confused and has slurred speech is the highest priority client, as these are signs of a possible stroke, which is a medical emergency. The nurse should assess the client for other signs of stroke, such as facial drooping, arm weakness, and vision problems, and initiate the stroke protocol, which includes calling for help, obtaining a CT scan, and administering thrombolytic therapy if indicated.

Choice D reason: A client who has chemical burns covering 20% of the total body surface area is a priority client, but not the highest priority. The nurse should assess the client for signs of airway injury, infection, and fluid loss, and provide wound care, pain relief, and fluid resuscitation. However, the client's condition is not as urgent or life-threatening as the other clients.

A. Secure the client's restraints with a square knot B. Attach the restraints to the fixed portion of the frame of the client's bed C. Remove the client's restraints every 2 hours D. Allow 1 fingerbreadth between the restraint and the client's wrists

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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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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