A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take?

A. Reporting the incident to the charge nurse is incorrect as the first step. While this action may be necessary if the issue continues, the immediate step should be to intervene directly to stop the conversation and prevent further breach of confidentiality.

B. Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client’s medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client’s privacy is respected.

C. Participating in an in-service about client confidentiality is incorrect as the first step. While in-service education on client confidentiality is important, it is not an immediate action to address a current breach of confidentiality.

D. Speaking to the staff members in private about client confidentiality is incorrect. While private conversation is important to address the issue further, the first action is to stop the conversation immediately to prevent any further privacy violations.

A. “Discontinue the medication. I will ask your provider for another antibiotic.”: This is correct. Ciprofloxacin and other fluoroquinolones are associated with a risk of tendonitis and tendon rupture, particularly in the Achilles tendon. The pain in the calf muscle could indicate this side effect. The nurse should recommend discontinuing the medication and notifying the provider for further evaluation.

B. “That reaction means your dose is too high. Cut the pill in half.”: This is incorrect. The pain in the calf muscle is likely related to a known side effect of ciprofloxacin, rather than the dose being too high. Adjusting the dose is not the appropriate solution.

C. “Continue to take the medication. Calf pain is a minor reaction that will resolve itself.”: This is incorrect. Calf pain may be indicative of a serious side effect, such as tendonitis or tendon rupture, and the medication should be discontinued until the provider evaluates the client.

D. “This is an allergic reaction. Take the medication with an antihistamine.”: This is incorrect. The pain in the calf muscle is more likely due to tendon-related side effects, not an allergic reaction. Ciprofloxacin-related tendon pain requires immediate attention, and antihistamines would not address the underlying issue.