The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

Ask the colleague why the action is being performed.

Remind the colleague of information security principles.

Send email to facility administrators reporting the action.

Comment about the action on a staff discussion board.

Answer and Explanation

The Correct Answer is B

A.   While this may provide some insight into the colleague's motivations, it doesn't directly address the issue of patient privacy and confidentiality.
B.   Reminding the colleague of information security principles helps reinforce the importance of maintaining client confidentiality and proper handling of sensitive information. This action promotes awareness and correction of improper practices without escalating the situation unnecessarily.
C.   Reporting the issue to the facility administrators may be necessary if the colleague continues to violate privacy and confidentiality principles. However, it's important to address the issue directly with the colleague first.
D.   Publicly discussing the issue on a staff discussion board could be embarrassing for the colleague and may not be the most effective way to address the problem.

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Correct Answer is B

Explanation

A. A serum hemoglobin level of 16 g/dL (160 g/L) is within the normal reference range for adults (14 to 18 g/dL). Hemoglobin levels that are within the normal range generally do not indicate a direct risk for falls. Low hemoglobin (anemia) could potentially increase fall risk due to fatigue or dizziness, but a normal level is not a risk factor for falls.
B. Opioid analgesics are known to have side effects such as sedation, dizziness, and impaired motor coordination, which can increase the risk of falls. The recent administration of opioids makes this a significant factor in assessing fall risk, as the client may still be experiencing side effects from the medication that could impair their balance or cognitive function.
C. Depression can contribute to fall risk in several ways, including reduced motivation to engage in activities, decreased physical strength, and impaired attention. However, while important to address, depression alone is not as immediate or direct a risk factor for falls compared to factors like recent medication side effects or actual physical impairments.
D. Stooped posture may be indicative of issues such as musculoskeletal problems or balance difficulties. However, if the client has a steady gait, it suggests that despite the stooped posture, their current ability to walk is stable. The stooped posture alone might increase fall risk over time, but it is not as directly related to the immediate risk of falls as recent medication effects.

A. Determine which member of the nursing staff brought the cup of coffee to the client. B. Consult with the dietician to learn if the client is allowed to drink coffee. C. Remove the coffee from the tray, advising the client that it is not included in the diet. D. Remind the client that no milk or creamer can be added to the coffee.

Correct Answer is C

Explanation

A. While it’s important to understand how the coffee ended up on the tray, determining which staff member made the mistake does not address the immediate issue of ensuring the client’s diet is appropriate. The priority should be to correct the dietary error and ensure that the client receives only what is appropriate for their diet.
B. Consulting with a dietician could provide clarity on dietary restrictions and allowances. However, if the client is on a clear liquid diet, coffee is typically not included because it may have additives (like milk or creamer) or may not be considered suitable for the clear liquid diet.
C. Coffee, unless specified as permissible, generally does not meet the criteria for a clear liquid diet due to its potential to be mixed with non-clear substances and its stimulant properties. Removing the coffee and informing the client of the dietary restriction ensures that the client adheres to the prescribed diet and avoids potential complications or issues with their treatment.
D. This action is not suitable for a clear liquid diet. Coffee itself is typically not allowed on a clear liquid diet, regardless of whether milk or creamer is added. This choice does not address the fundamental issue of the coffee being inappropriate for the client’s diet.

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The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

Correct Answer is B

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is C

Explanation

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