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 AP's actions.
Submit an incident report to the risk manager.
The Correct Answer is A
Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.
When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.
The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: a. Temperature 38.8° C (101.8° F)
Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.
Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.
Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.
Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.
Correct Answer is D
Explanation
Blurred vision in the third trimester of pregnancy can be a potential sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage.
Shortness of breath when climbing stairs is a common symptom in the third trimester as the growing uterus puts pressure on the diaphragm and limits lung expansion. While it is important to monitor the client's respiratory status, it is not an immediate cause for concern unless accompanied by severe or persistent shortness of breath.
Leukorrhea refers to an increase in vaginal discharge during pregnancy, which is a normal physiological change. It is typically white or clear and does not indicate any immediate problems unless it is accompanied by other symptoms such as itching, foul odor, or irritation.
Numbness or tingling in the fingers during pregnancy can be caused by pressure on nerves due to fluid retention or changes in the body's circulation. While it can be uncomfortable, it is not typically considered an urgent issue unless it is severe, persistent, or accompanied by other concerning symptoms.
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