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.

Answer and Explanation

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.

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Correct Answer is A, B, C, D, E

Explanation

To set up a sterile field for changing a dressing on an abdominal wound, the nurse should perform the following steps in sequence: First, prepare a dry work surface above waist level to ensure that the sterile field is maintained at a height that minimizes the risk of contamination. Next, open the outside cover of the sterile kit and carefully remove the dust cover, which protects the inner contents from contamination. Then, grasp the outermost flap of the sterile kit and open it away from the body, avoiding any abrupt movements that could compromise sterility. After that, open each side flap of the sterile kit individually, pulling them to the side and making sure not to reach over the sterile field. Finally, open the innermost lower flap of the sterile kit while standing away from the sterile field to prevent contamination from the nurse's clothing or body. These steps help maintain the sterility of the dressing and the instruments, which is crucial for preventing infection at the wound site.

A. Notify the provider of the client's refusal. B. Document the refusal in the client's medical record. C. Inform the client of the potential consequences of their refusal. D. Return the medication to the medication cabinet.

Correct Answer is C

Explanation

A. While eventually informing the provider may be necessary, it's important for the nurse to first address the client's concerns directly.
B. Documenting the refusal is important but should occur after addressing the client's concerns.
C. This action allows the nurse to educate the client about the potential risks of not taking the medication, facilitating informed decision-making.
D. Returning the medication is premature until the client's concerns have been addressed and a decision has been made regarding the medication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A, B, C, D, E

Explanation

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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