A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

An assistive personnel is informing a friend of the client about their condition.

A nurse and a provider are discussing a client's condition at the nurses' station while a visitor is present.

An assistive personnel logs out of the computer prior to responding to a call light.

A nurse is faxing data about a client to a preferred provider.

A nurse is reviewing an electronic list of all clients admitted to the unit.

Answer and Explanation

Correct Answer : A,B,E

A. This is a clear breach of confidentiality as sharing client information with individuals who are not part of the healthcare team and without the client's consent violates patient privacy.

B. Discussing a client’s condition in a public area where unauthorized individuals (like visitors) can overhear is a breach of confidentiality. Patient information should be discussed in private settings to protect the client's privacy.

C. This action is a good practice to protect patient information and does not breach confidentiality.

D. This is acceptable as long as proper protocols are followed, such as using secure fax lines and confirming that the receiving party is authorized to receive the information. This action does not inherently breach confidentiality.

E. If the nurse is not involved in the care of all those clients and does not have a legitimate reason to access that information, this action can also be considered a breach of confidentiality. Healthcare providers should only access information relevant to their role and responsibilities.

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Correct Answer is C

Explanation

Choice A Reason:
The time the client received his last dose of pain medication is incorrect. While this information is relevant for ongoing pain management, it may not be as critical for the receiving facility unless there are specific pain management protocols in place that need to be followed.
Choice B Reason:
The client's preferred time for bathing is incorrect. While knowing the client's preferences is important for providing individualized care, the preferred time for bathing may not be immediately pertinent to the client's care upon transfer to the rehabilitation facility.
Choice C Reason:
The steps to follow when providing wound care is correct. This information is essential for the receiving facility to ensure proper wound care continues without interruption. It helps ensure consistency in care and minimizes the risk of complications related to wound healing.
Choice D Reason:
The belief that the client has a difficult relationship with his son is incorrect. While psychosocial information about the client is important for holistic care, it may not be the most crucial information to include in the change-of-shift report for transfer to a rehabilitation facility unless it directly impacts the client's medical care or rehabilitation plan.

A. Tell the client that their blood alcohol level will be checked. B. Inform the client that a catheter will be inserted. C. Document the client's refusal in their chart. D. Assess the client for urinary retention.

Correct Answer is C

Explanation

Choice A Reason:
Telling the client that their blood alcohol level will be checked is incorrect. Threatening the client with other forms of testing may not be ethically or legally appropriate, especially if the client has refused the initial request. It's important to respect the client's autonomy and right to refuse testing.
Choice B Reason:
Informing the client that a catheter will be inserted is incorrect. Inserting a catheter against the client's will is invasive and would constitute a violation of the client's autonomy and bodily integrity. It is not an appropriate action.
Choice C Reason:
Documenting the client's refusal in their chart is correct. Documenting the client's refusal is essential for accurate record-keeping and ensures that the healthcare team is aware of the client's decision. It also helps protect the nurse and the healthcare facility in case of any legal or ethical challenges related to the client's refusal.
Choice D Reason:
Assessing the client for urinary retention is incorrect. While urinary retention may be a concern in some cases, it is not the immediate action to take when a client refuses to provide a urine sample. The priority is to respect the client's autonomy and document their refusal appropriately. If there are clinical indications or concerns about urinary retention, they can be assessed separately and addressed accordingly.

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A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client refuses to provide a urine sample to check for substance use. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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