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. What is the best nursing action?
Write an incident report and submit it to the unit manager.
Try not to listen to the conversation since it is confidential.
Approach the individuals involved and ask them to stop.
Tell the client of the UAP's concern for him.
The Correct Answer is C
A. Write an incident report and submit it to the unit manager: Filing an incident report is appropriate for serious breaches of protocol, but the immediate priority is to stop the inappropriate discussion to protect client confidentiality.
B. Try not to listen to the conversation since it is confidential: Ignoring the conversation does not address the violation of privacy that is occurring. The PN has a professional responsibility to intervene when confidentiality is breached.
C. Approach the individuals involved and ask them to stop: Directly intervening ensures the conversation ceases and reinforces the importance of client confidentiality. Immediate action protects the client’s privacy and maintains professional standards of care.
D. Tell the client of the UAP's concern for him: Sharing details of the conversation with the client would further breach confidentiality and is inappropriate. The PN’s focus should be on stopping the discussion among staff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Urinary output: Monitoring urinary output is important for clients on chemotherapy due to renal toxicity risk, but it is unrelated to the localized effects of stomatitis. The priority in stomatitis is maintaining oral intake and preventing nutritional compromise.
B. Frequency of bowel movements: Bowel patterns may be affected by chemotherapy or medication use, yet they do not directly relate to oral mucosal inflammation. Stomatitis primarily interferes with eating and drinking rather than bowel elimination.
C. Ability to swallow: Assessing the client’s ability to swallow is most important because stomatitis causes painful ulcerations and inflammation in the mouth, which can impair eating, drinking, and medication administration. Difficulty swallowing increases the risk of malnutrition, dehydration, and weight loss.
D. Blood pressure while standing: Orthostatic blood pressure measurement is relevant for assessing fluid balance or cardiovascular stability but has no direct connection to stomatitis. The priority is evaluating how oral pain and lesions affect intake and swallowing safety.
Correct Answer is D
Explanation
A. Reinforce PCA pump teaching: Teaching about PCA use is important, but it is not the immediate priority when a client shows signs of lethargy. Education can be addressed later, once the client’s condition has been stabilized and safety is ensured.
B. Check the IV insertion site for swelling: Inspecting the IV site for infiltration or phlebitis is a routine step, but it does not address the potential systemic effect of morphine causing central nervous system depression.
C. Determine the client's pain scale rating: Assessing pain level is typically part of routine evaluation for clients on PCA, but when lethargy develops, the focus must shift to assessing possible opioid toxicity rather than pain relief effectiveness.
D. Measure the client's vital signs: Obtaining vital signs is the most immediate and appropriate action. Respiratory depression, hypotension, or bradycardia may indicate opioid overdose or excessive sedation. Prompt assessment allows the PN to recognize early signs of morphine toxicity and intervene quickly to prevent respiratory compromise.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.