A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
Report the incident to the charge nurse.
Tell the staff members to stop their discussion.
Participate in an in-service about client confidentiality.
Speak to the staff members in private about client confidentiality.
The Correct Answer is B
A. Reporting the incident to the charge nurse is incorrect as the first step. While this action may be necessary if the issue continues, the immediate step should be to intervene directly to stop the conversation and prevent further breach of confidentiality.
B. Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client’s medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client’s privacy is respected.
C. Participating in an in-service about client confidentiality is incorrect as the first step. While in-service education on client confidentiality is important, it is not an immediate action to address a current breach of confidentiality.
D. Speaking to the staff members in private about client confidentiality is incorrect. While private conversation is important to address the issue further, the first action is to stop the conversation immediately to prevent any further privacy violations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Injecting 15 units of air into the regular insulin vial is correct. When drawing up two types of insulin, the nurse should first inject air into the NPH (cloudy) insulin vial without withdrawing the medication. Then, the nurse should inject air into the regular (clear) insulin vial before withdrawing the regular insulin. This prevents contamination and maintains proper insulin mixing procedures.
B. Placing the cap over the needle is incorrect. Once insulin preparation has started, recapping the needle is unnecessary and increases the risk of contamination or needlestick injury.
C. Verifying the dosage with another nurse is incorrect at this stage. Dosage verification should be done after the correct amounts of insulin are drawn into the syringe, not before.
D. Withdrawing 10 units of NPH insulin is incorrect. The nurse should first withdraw the regular (clear) insulin before drawing up the NPH (cloudy) insulin to avoid contaminating the regular insulin with the longer-acting insulin.
Correct Answer is B
Explanation
A. Carrying the baby to the nursery is incorrect. Most facilities require that newborns be transported in a bassinet, not carried, to reduce the risk of accidental drops or abductions.
B. Having an identification band that matches the baby’s band is correct. Hospital security protocols require that the mother and baby wear matching identification bands to ensure the right baby is with the right parent and prevent infant abduction or misidentification.
C. Removing the security band to give to a family member is incorrect. The security band must remain on the mother at all times to verify identity when interacting with the baby. Removing it can compromise security.
D. Taking the baby to the lobby to visit family is incorrect. Many hospitals have strict policies requiring newborns to remain in designated areas for security and infection control reasons. Visitors should come to the mother’s room instead.
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