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 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.

A. C-reactive protein level. B. Culture for sensitive organisms. C. Serum albumin. D. Serum blood glucose (BG) level.

Correct Answer is B

Explanation

A. CRP is an acute-phase protein produced by the liver in response to inflammation. Elevated CRP levels indicate systemic inflammation or infection. Measuring the CRP level can help confirm the presence of an inflammatory process, such as infection, and monitor the severity of inflammation. However, while useful, CRP alone might not provide the complete picture needed for specific wound management.
B. Culturing the wound for sensitive organisms is crucial when an infection is suspected. This test will identify the specific bacteria or other pathogens causing the infection and determine their sensitivity to various antibiotics. This information is essential for choosing the appropriate treatment to address the infection effectively.
C. Serum albumin levels provide information about the client’s nutritional status and can reflect protein malnutrition. Low serum albumin levels can indicate poor wound healing due to inadequate protein levels, which affects tissue repair. While serum albumin is important for understanding overall nutritional status, it does not directly diagnose or confirm infection.
D. Blood glucose levels are important to monitor, especially in diabetic patients, as high blood glucose can impair wound healing and increase the risk of infections. However, blood glucose levels are more related to the client's ability to heal rather than directly identifying or managing an infection.

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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

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

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

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