The practical nurse (PN) overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. Which is the best nursing action?
Approach the individuals involved and ask them to stop.
Tell the client of the UAP's concern for him.
Try not to listen to the conversation since it is confidential.
Write an incident report and submit it to the unit manager.
The Correct Answer is A
A. Approach the individuals involved and ask them to stop:
Immediate intervention stops the breach of confidentiality and maintains client privacy.
B. Tell the client of the UAP's concern for him:
Would further violate confidentiality and harm trust.
C. Try not to listen to the conversation since it is confidential:
Passive approach; does not stop the breach.
D. Write an incident report and submit it to the unit manager:
May be needed afterward, but first action is to stop the conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Dependent edema:
Fluid volume overload leads to increased hydrostatic pressure in capillaries, causing fluid to shift into the interstitial spaces, particularly in dependent areas like the legs, ankles, and sacrum.
B. Inelastic skin turgor:
Inelastic skin turgor is typically a sign of dehydration, not fluid overload. Overhydrated clients often have taut, stretched skin, not decreased elasticity.
C. Complaints of thirst:
Thirst is a compensatory mechanism for dehydration or hypernatremia, not for fluid overload.
D. Tachycardia:
Excess fluid increases the workload of the heart, which can lead to an increased heart rate as a compensatory mechanism.
E. Moist lung sounds:
Fluid volume overload can cause pulmonary congestion, leading to crackles or moist lung sounds due to fluid accumulation in the alveoli.
Correct Answer is C
Explanation
A. Cornstarch: Not used; may harbor bacteria and irritate the skin.
B. Petroleum jelly: Can interfere with the adherence of the colostomy pouch seal.
C. Stoma adhesive product: Creates a protective barrier to prevent skin breakdown and ensures a secure pouch seal.
D. Antiseptic cream: Can be irritating to peristomal skin and interfere with pouch adhesion.
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