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 D

Explanation

A. This can strain the back and increase the risk of injury. It's important to use proper body mechanics, such as bending the knees and keeping the back straight, when reaching for objects.
B. Bending at the waist can strain the back and increase the risk of injury. It's important to lift objects with the legs, not the back.
C. This can strain the back and hips. It's important to use proper body mechanics, such as using the legs and core muscles to push or pull heavy objects.
D. Standing erect with knees bent provides a strong base of support and helps to distribute weight evenly. Bending the knees allows for lifting with the legs, which is less stressful on the back and reduces the risk of injury. Pulling a draw sheet and moving a client in bed requires a combination of strength and proper body mechanics. Standing erect with knees bent helps to prevent strain on the back and muscles

A. 4+ pitting edema of both lower extremities. B. Hypoactive bowel sounds with infrequent bowel movements. C. Braden risk assessment scale rating score of ten. D. Warm, dry skin with a fever of 100.0° F (37.8° C).

Correct Answer is C

Explanation

A. Pitting edema, especially at a 4+ level, indicates significant fluid retention in the lower extremities. While this can be a concern for skin integrity and may contribute to skin breakdown due to increased pressure and reduced mobility, it is not the most direct indicator for turning schedules.
B. Hypoactive bowel sounds and infrequent bowel movements suggest gastrointestinal issues, such as constipation or reduced bowel motility. While these issues are important to address for overall client health, they do not directly impact the scheduling of turning to prevent pressure ulcers.
C. The Braden Risk Assessment Scale is a tool used to evaluate a client's risk for developing pressure ulcers. A score of 10 indicates a high risk for pressure ulcer development. This assessment directly informs the need for a more aggressive turning schedule and other preventive measures to protect skin integrity.
D. Warm, dry skin and a low-grade fever might indicate an infection or other underlying condition, but these factors are not the primary considerations for determining the turning schedule. While fever and skin temperature can be important for overall assessment and care, they do not directly impact the need for turning to prevent pressure ulcers.

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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?

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Naxlex Comprehensive Predictor Exams

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