A nurse is reinforcing teaching with a newly licensed assistive personnel (AP) who has violated a client's confidentiality. Which of the following actions should the nurse take? (Select all that apply.)

Decline documenting the first counseling session.

Communicate expected behavior to the AP.

Explain to the AP the consequences of the behavior.

Allow the AP time to respond to the counseling information.

Conduct the counseling session with another AP present.

Answer and Explanation

Correct Answer : B,C,D

A.   Decline documenting the first counseling session: Documentation is necessary to maintain accurate records of counseling sessions.
B.   Communicate expected behavior to the AP: Reinforcing the expectations helps clarify appropriate behavior.
C.   Explain to the AP the consequences of the behavior: Understanding potential consequences encourages adherence to confidentiality standards.
D.   Allow the AP time to respond to the counseling information: Allowing the AP to respond fosters a two-way communication approach and encourages accountability.
E.   Conduct the counseling session with another AP present: Counseling sessions should remain private to maintain confidentiality.

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Correct Answer is A

Explanation

A. Inform the charge nurse. The charge nurse should be notified when consent cannot be obtained so appropriate steps can be taken, such as rescheduling or involving the healthcare provider.
B. Send the client for the test with the unsigned form. Consent must be obtained before any invasive procedure. Proceeding without consent can result in legal and ethical consequences.
C. Obtain consent from a family member. A family member cannot give consent unless they hold legal power of attorney for healthcare decisions.
D. Wake the client and ask them to sign the form. Consent obtained under the influence of sedatives is not legally valid as it compromises the client's decision-making capacity.

A. "Have you tried holding your infant skin-to-skin?" B. "Have you considered joining a parents' support group?" C. "What is your infant's level of activity?" D. "Is your infant able to latch on during breastfeeding?"

Correct Answer is D

Explanation

A. "Have you tried holding your infant skin-to-skin?": Important for bonding and soothing but not the priority for postoperative care.
B. "Have you considered joining a parents' support group?": Beneficial for emotional support but not immediately essential for the infant's recovery.
C. "What is your infant's level of activity?": Relevant for assessing overall recovery but not the most critical issue.
D. "Is your infant able to latch on during breastfeeding?" Feeding is the priority concern after cleft palate repair to ensure adequate nutrition and assess for complications.

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A nurse is reinforcing teaching with a newly licensed assistive personnel (AP) who has violated a client's confidentiality. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

Correct Answer is D

Explanation

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