A nurse discovers information about a client on a colleague's social media page. Which of the following actions should the nurse take?
Speak to a first-level manager about the social media post.
Gather additional information from other colleagues.
Inform the client about the social media post.
Ask the colleague why the information was posted.
The Correct Answer is A
A. Speak to a first-level manager about the social media post: Reporting the social media post to a first-level manager ensures that the situation is handled through proper administrative and professional channels. This protects client confidentiality, aligns with HIPAA regulations, and maintains professional accountability.
B. Gather additional information from other colleagues: Seeking additional information from peers may violate confidentiality and is not an appropriate method for addressing potential breaches of client privacy. The concern should be escalated through formal reporting channels rather than informal investigation.
C. Inform the client about the social media post: Directly informing the client may not be appropriate without guidance from administration or risk management, as it could complicate investigation or legal procedures. The issue should first be reported to management for proper handling.
D. Ask the colleague why the information was posted: Confronting the colleague directly could lead to defensiveness, workplace conflict, or compromised evidence. The appropriate first step is to report the concern to a supervisor rather than attempt immediate resolution with the colleague.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bulging fontanel: A bulging fontanel typically indicates increased intracranial pressure, not dehydration. In dehydration, the fontanel is more likely to appear sunken in infants, making this an incorrect finding to monitor for fluid loss.
B. Weight loss: Weight loss is a key indicator of fluid loss in infants. Monitoring daily weight provides an objective measure of dehydration severity and effectiveness of rehydration interventions, making it a critical finding for the nurse to track.
C. Distended jugular vein: Jugular vein distention is associated with fluid overload or cardiac issues, not dehydration. This finding would be unlikely in a 3-month-old infant with gastroenteritis.
D. Bradycardia: Dehydration in infants typically presents with tachycardia as the body compensates for decreased fluid volume. Bradycardia is not a common sign of dehydration and may indicate another underlying condition.
Correct Answer is D
Explanation
A. Clean the insertion site with betadine: While povidone-iodine (Betadine) can be used, current guidelines recommend using chlorhexidine for central line site care because it is more effective in preventing catheter-related bloodstream infections. Using betadine is not the preferred standard of care.
B. Flush the catheter with sterile water: Central venous catheters should be flushed with sterile saline, not sterile water, to maintain patency and avoid hemolysis or electrolyte imbalance. Flushing with water can damage blood cells and the catheter.
C. Use a 5-mL syringe to flush the catheter: A minimum of a 10-mL syringe is recommended when flushing a central venous catheter because smaller syringes generate excessive pressure that can damage the catheter. Using a 5-mL syringe increases the risk of catheter rupture.
D. Wear sterile gloves when providing site care: Sterile technique is required when performing central line site care to prevent infection. Wearing sterile gloves protects the client from pathogens and is a critical step in maintaining asepsis during dressing changes and catheter maintenance.
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