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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Using patterned-paced breathing is typically associated with labor pain management rather than postoperative pain following a cesarean birth. While controlled breathing can help with discomfort, it is not the most effective strategy for incision-related pain.

B. Changing positions as little as possible is incorrect. Early mobility is encouraged after a cesarean birth to promote circulation, prevent complications like deep vein thrombosis, and aid recovery. Avoiding movement can lead to stiffness and prolonged discomfort.

C. Splinting the incision with a pillow is correct. Holding a pillow firmly against the incision while changing positions provides support, reduces strain on the abdominal muscles, and minimizes pain during movement.

D. Applying counterpressure to the back is incorrect. Counterpressure is a technique used for back labor pain during childbirth and is not relevant for post-cesarean incision pain.

A. Measure the client's abdominal girth daily. B. Keep the client's daily protein intake below 0.8 g/kg. C. Restrict the client's sodium intake to 3 g per day. D. Position the client supine with legs elevated.

Correct Answer is A

Explanation

A. Measure the client's abdominal girth daily is correct. Ascites is characterized by fluid accumulation in the abdomen. Measuring abdominal girth regularly is important for monitoring changes in the amount of fluid retention and for assessing the progression of ascites. It is a standard nursing intervention for clients with this condition.

B. Keep the client's daily protein intake below 0.8 g/kg is incorrect. Protein intake should not be restricted to this extent. In fact, adequate protein is important for liver health and to prevent muscle wasting in clients with cirrhosis, unless there are complications such as hepatic encephalopathy.

C. Restrict the client's sodium intake to 3 g per day is incorrect. Sodium intake is typically restricted more severely for clients with ascites. The general recommendation is often less than 2 g per day to help prevent fluid retention and reduce the burden on the heart and kidneys.

D. Position the client supine with legs elevated is incorrect. While elevating the legs can help reduce edema in the legs, positioning the client supine does not provide the same benefit for ascites. Side-lying with legs elevated or sitting with the legs elevated may be more beneficial.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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