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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The occiput refers to the back of the head. Placing a small pillow or padding under the occiput can help relieve pressure and provide support to the client's head and neck when they are placed in the supine position.
Breasts: When in the prone position, breasts may be compressed or flattened. To relieve pressure, it may be necessary to use positioning techniques that distribute weight evenly and avoid direct pressure on the breasts, such as using cushions or foam pads to support the chest and torso.
Heels: The heels are prone to pressure ulcers when a client is lying in the supine position for extended periods. To relieve pressure, it is important to use proper heel offloading techniques, such as placing heel protectors or pillows under the lower legs to elevate the heels off the bed surface and prevent direct pressure.
Coccyx: The coccyx is the tailbone region at the base of the spine. When in the supine position, pressure on the coccyx can be relieved by using a cushion or padding under the pelvic area, specifically under the bony prominence of the coccyx, to reduce direct pressure and provide comfort.
Correct Answer is B
Explanation
A. Incorrect. While a client scheduled for surgery is important, addressing the client with elevated blood pressure and a headache takes priority.
B. Correct. The client with elevated blood pressure and a headache requires immediate assessment, as these symptoms could indicate a hypertensive crisis or other serious complications.
C. Incorrect. While addressing postoperative nausea is important, the client with elevated blood pressure and headache requires more immediate attention.
D. Incorrect. A client with a Jackson Pratt drain may need care and assessment, but a client with elevated blood pressure and a headache has a more urgent need for evaluation.
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