A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take?

Contact the nurse manager.

Call risk management to interview the client.

Reassure the client that the staff is well trained.

Document in the client's chart that an incident report has been filed.

Answer and Explanation

The Correct Answer is A

A.   Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B.   Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C.   Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D.   Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.

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Correct Answer is D

Explanation

Choice A Rationale: While it is important to identify the staff member responsible for leaving sensitive information accessible, it is not the first action that should be taken. The immediate risk of a confidentiality breach must be addressed before investigating the cause.
Choice B Rationale: Notifying the charge nurse is a necessary step, but it is not the most immediate action required. The priority is to secure the confidentiality of the client's information.
Choice C Rationale: Informing the visitor about the confidentiality of records is crucial, but the first action should be to prevent further viewing of the information.
Choice D Rationale: Closing the computer program is the first and most direct action to secure the client's medical information and prevent any further unauthorized access. This action immediately addresses the privacy breach and protects the client's confidential information.

A. "I will instruct visitors to wear a mask when visiting a client who is on contact precautions." B. "I will place a client who has compromised immunity in a negative-pressure airflow room." C. "I will have a client who is on airborne precautions wear a mask when out of her room." D. "I will wear an N95 respirator mask when caring for a client who is on droplet precautions"

Correct Answer is C

Explanation

A. Contact precautions typically involve wearing gloves and a gown to prevent the spread of infectious agents through direct contact. Masks are not generally required for visitors unless the client is also on droplet or airborne precautions. Therefore, this statement reflects a misunderstanding of the specific requirements for contact precautions.
B.A client with compromised immunity should be placed in a positive-pressure airflow room, not a negative-pressure room. Positive-pressure rooms help prevent outside contaminants from entering the room, thereby protecting the immunocompromised client.
C. Clients on airborne precautions (e.g., for tuberculosis, varicella, or measles) should wear a mask if they need to leave their room to prevent the spread of airborne pathogens to others. This helps to contain infectious particles and protect others from exposure.
D. An N95 respirator mask is required for airborne precautions, not droplet precautions. For droplet precautions (e.g., for influenza, pertussis), a standard surgical mask is sufficient to protect against respiratory droplets.

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A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take?

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