A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
Complete an incident report about the breach of confidentiality.
Tell the nurse that permission from the risk manager is required to view the client's record.
Remind the nurse that only staff caring for the client may access the client's record.
Contact facility security to remove the nurse from the unit.
The Correct Answer is C
A. Completing an incident report about the breach of confidentiality may be necessary, but it
should not be the first action. The immediate concern is addressing the behavior and reminding the nurse of proper protocol.
B. While it may be true that permission from the risk manager is required to access certain
records, this response does not address the immediate issue of the unauthorized access. It's more important to address the behavior directly.
C. This is the most appropriate action because it directly addresses the unauthorized access to the client's medical record. Reminding the nurse of the proper protocol for accessing medical records can help prevent further breaches of confidentiality.
D. Contacting facility security to remove the nurse from the unit may be excessive at this stage and should be considered if the behavior persists after reminders about proper protocol.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While repositioning is important for comfort and preventing pressure ulcers, repositioning every 4 hours may not be sufficient, and it does not directly address the client's dyspnea.
B. Circulating air with a fan can help reduce the sensation of breathlessness and improve comfort for clients experiencing dyspnea. This non-invasive measure can be effective in relieving symptoms.
C. Placing the head of the bed flat is generally not recommended for clients with dyspnea, as it can worsen breathing difficulties. Elevating the head of the bed is usually more helpful.
D. Frequent oral care is important for maintaining comfort, especially in end-of-life care, but every 8 hours might not be sufficient. More frequent oral care is typically needed, and while important, this does not directly address dyspnea.
Correct Answer is B
Explanation
A. Increased hunger: Dysphagia is not typically associated with increased hunger.
B. Garbled voice: Difficulty swallowing (dysphagia) can result in a garbled or hoarse voice due to food or liquid entering the airway.
C. Sneezing: While sneezing is not typically associated with dysphagia, it can be a response to irritants in the nasal passages.
D. Rapid chewing: Rapid chewing is not necessarily indicative of dysphagia and may occur for various reasons, such as habit or anxiety.
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