A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg.
Which of the following actions should the nurse take to protect the client's confidentiality?

Provide a verbal report of the client's condition to the paramedic performing the transfer.

Fax the client's name and identifiable information to the rehabilitation facility.

Email the client's health information to the facility in an unencrypted file.

Discuss the client's response to the transfer with another staff nurse.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Providing a verbal report of the client's condition to the paramedic performing the transfer violates the client's confidentiality. Protected health information should not be disclosed verbally to individuals who do not have a need to know. Confidentiality must be maintained during all stages of care, including transfers.

Choice B rationale:

Faxing the client's name and identifiable information to the rehabilitation facility is not a secure method of transmitting sensitive health information. Faxed documents can be intercepted, compromising the client's confidentiality. Secure electronic methods or encrypted communication should be used for transmitting such information.

Choice C rationale:

Emailing the client's health information to the facility in an unencrypted file is also insecure and violates the client's confidentiality. Unencrypted emails can be intercepted and read by unauthorized individuals. Protected health information should be transmitted using secure, encrypted methods to maintain confidentiality.

Choice D rationale:

Discussing the client's response to the transfer with another staff nurse is inappropriate and breaches confidentiality. Sharing patient information, even within the healthcare team, should only be done on a need-to-know basis and in a secure, private setting.

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Correct Answer is C

Explanation

Choice A rationale:

Offering small amounts of clear liquids 6 hours following surgery is generally appropriate, but it doesn't specifically address the child's pain management. Pain control is essential postoperatively, and the best approach is to administer analgesics as prescribed by the healthcare provider.

Choice B rationale:

Applying a warm compress to the operative site once daily can provide comfort and may help reduce localized pain or swelling. However, this alone might not be sufficient for pain management, especially in the immediate postoperative period.

Choice C rationale:

(Correct Choice) Administering analgesics on a scheduled basis for the first 24 hours is essential for managing postoperative pain effectively. Pain can interfere with the child's recovery, breathing, and overall well-being. Scheduled pain medications ensure a consistent level of pain relief, allowing the child to rest and recover more comfortably.

Choice D rationale:

Cromolyn nebulized solution is used to prevent asthma symptoms and allergic reactions. It is not typically indicated for postoperative pain management. Providing appropriate analgesics, as prescribed, is the standard of care for managing pain in a postoperative child.

A. Ask the client for permission to take photographs. B. Provide community sexual assault support contacts. C. Document the client's verbatim statements. D. Determine any physical signs of injury.

Correct Answer is D

Explanation

The correct answer is choice d. Determine any physical signs of injury.

Choice A rationale:

Asking the client for permission to take photographs is important for forensic evidence, but it should not be the first action. The nurse must first ensure the client’s immediate physical well-being.

Choice B rationale:

Providing community sexual assault support contacts is crucial for the client’s long-term support and recovery, but it is not the immediate priority in an emergency assessment.

Choice C rationale:

Documenting the client’s verbatim statements is essential for legal and medical records, but it should follow the initial physical assessment to address any urgent medical needs.

Choice D rationale:

Determining any physical signs of injury is the first priority. This ensures that any immediate medical needs are addressed, which is critical for the client’s safety and well-being.

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A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg.Which of the following actions should the nurse take to protect the client's confidentiality?

Nursing Test Bank

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A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg.
Which of the following actions should the nurse take to protect the client's confidentiality?