A nurse overhears two assistive personnel (AP. in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

Tell the APS to stop the conversation.

Document the event in the client's progress notes.

Inform the client of the APs' actions.

Submit an incident report to the risk manager.

Answer and Explanation

The Correct Answer is A

A.   Correct. Overhearing private client information being discussed by staff members violates the client's right to privacy and confidentiality. The nurse should address the situation immediately and instruct the assistive personnel to stop the conversation.
B.   Incorrect. While documenting the event in the client's progress notes may be necessary, addressing the inappropriate behavior of the assistive personnel takes precedence.
C.   Incorrect. Informing the client about the conversation is not necessary and may further compromise the client's sense of privacy.
D.   Incorrect. Submitting an incident report to the risk manager might be necessary, but the immediate action should be to stop the conversation and address the breach of confidentiality.

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Correct Answer is B

Explanation

A. Incorrect. Maintaining abduction of the residual limb with a pillow is not relevant to promoting mobility and independence for a client with an above-the-knee amputation.
B. Correct. Encouraging the client to use the overbed trapeze can help the client perform upper body movements and reposition independently, which is essential for maintaining mobility.
C. Incorrect. Avoiding a prone position may not be necessary for the client after an above-the-knee amputation and does not directly contribute to mobility and independence.
D. Incorrect. Keeping a loose, absorbent dressing over the surgical site is important for wound care, but it does not directly promote mobility and independence.

A. Place the bedside table 2 feet away from the bed. B. Move the client's bed to the main floor of the house. C. Keep lighting in the home dim. D. Place area rugs on slick floor surfaces.

Correct Answer is B

Explanation

A. Incorrect. The bedside table should be within easy reach of the bed to prevent the client from attempting to reach for items and potentially falling.
B. Correct. Moving the client's bed to the main floor of the house reduces the need for using stairs, which can be a fall risk for clients at risk for falls.
C. Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D. Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.

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A nurse overhears two assistive personnel (AP. in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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