A nurse is assisting in the care of a client who presents to the emergency department.

Exhibits

A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

An incident report is a tool used to document any unexpected or adverse event that occurs in the healthcare setting. It is important to report incidents to ensure proper investigation, analysis, and implementation of measures to prevent future occurrences.

In this example, the incident involves an error with an electronic IV pump resulting in the delivery of an incorrect amount of fluid, which can have serious implications for the client's safety and well-being.

The other examples listed may require further actions but may not necessarily require an incident report:

1. A nurse discovers that a client's family member has administered a PCA dose: While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.
2. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: While the observation of improper restraint removal raises concerns about proper restraint protocol, it is more appropriate to address this situation through immediate intervention and communication with the involved nurse and healthcare provider. Depending on the severity of the situation, an incident report may or may not be warranted, but it is not the primary action in this case.
3. A nurse observes a client vomiting after receiving an oral pain medication: While it is important to assess and address the client's condition and any adverse reactions, such as vomiting after receiving medication, it may not necessarily require an incident report. The nurse should assess the client, notify the healthcare provider, and document the incident appropriately in the client's medical record.

A.Giving change-of-shift report to a nurse outside the client's room ensures that client information is shared in a private, secure setting, reducing the risk of unauthorized individuals overhearing sensitive information.

B.While sharing information with staff involved in the client's care is generally acceptable, discussing detailed prognosis with assistive personnel (who may not have a need-to-know role) is inappropriate. Confidential information should only be shared with those directly involved in the patient's care as part of the care team.

C.This is a clear violation of confidentiality, as it exposes the client's private health information to anyone who may access the room.

D.This is a breach of confidentiality, as the information could be accessed by unauthorized individuals. The appropriate way to dispose of confidential information is to shred it or return it to the medical record.