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?
Tell the nurse that permission from the risk manager is required to view the client's record.
Contact facility security to remove the nurse from the unit.
Complete an incident report about the breach of confidentiality.
Remind the nurse that only staff caring for the client may access the client's record.
The Correct Answer is D
Rationale:
A. Telling the nurse that permission from the risk manager is required to view the client's record is not accurate and may not address the situation appropriately.
B. Contacting facility security to remove the nurse from the unit is not necessary and may not address the situation appropriately.
C. Completing an incident report about the breach of confidentiality may be appropriate later if the situation escalates or if there is no resolution after speaking to the nurse. However, the immediate step is to address the breach directly.
D. Reminding the nurse that only staff caring for the client may access the client's record is the correct action. The nurse should remind the colleague that access to a client's medical record is restricted to those directly involved in their care. This respects patient confidentiality and complies with legal and ethical guidelines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Applying lidocaine gel to the urethra may provide additional lubrication but does not address the immediate issue of resistance during catheter insertion.
B. Inflating the catheter's balloon is inappropriate at this stage, as the catheter is not properly positioned for urine flow, and doing so could cause injury.
C. Lowering the penis to a 45° angle helps to straighten the urethra and can facilitate easier passage of the catheter, making it the most appropriate action.
D. Twisting the catheter gently is not recommended, as this may cause trauma to the urethra or increase discomfort without resolving the resistance issue.
Correct Answer is D
Explanation
Rationale:
A. Wrist restraint orders typically require renewal every 24 hours, not every 36 hours.
B. Checking the client's range of motion every 6 hours is not specific to the use of wrist restraints.
C. Secure the restraints with a quick-release knot, not a square knot, to allow for quick removal in case of emergency.
D. Making sure two fingers fit under the restraints is important to ensure that they are not too tight and do not cause injury to the client.
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