A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.

Discarding worksheets containing client information in a wastebasket

Writing a client's diagnosis on the message board in the client's room

Giving change of shift report to a nurse outside the client's room

Discussing a client's prognosis with an assistive personnel who is caring for the client

Answer and Explanation

The Correct Answer is C

A. Discarding worksheets containing client information in a wastebasket does not ensure proper disposal of confidential information and could compromise confidentiality.
B. Writing a client's diagnosis on the message board in the client's room could breach confidentiality, as it could potentially be seen by unauthorized individuals.
C. This action protects client confidentiality because it involves discussing sensitive information in a private setting where unauthorized individuals are less likely to overhear. This is an appropriate method of communicating client information during a handoff.
D. While sharing relevant information with personnel directly involved in the client's care is generally acceptable, it must still be done in a manner that safeguards confidentiality.

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Correct Answer is A

Explanation

The correct answer is choicea. Obtain the client’s blood pressure in the other arm.

Choice A rationale:

Obtaining the client’s blood pressure in the other arm is crucial to avoid compromising the arteriovenous fistula. Measuring blood pressure in the arm with the fistula can damage the access site and impair its function.

Choice B rationale:

Encouraging the client to increase fluid intake is not appropriate for clients undergoing hemodialysis, as they often need to restrict fluid intake to prevent fluid overload.

Choice C rationale:

Reinforcing with the client to sleep on the side of the access site is incorrect. Clients should avoid sleeping on the arm with the fistula to prevent compression and potential damage to the access site.

Choice D rationale:

Obtaining the client’s weight is important for monitoring fluid balance, but it is not specific to the care of the arteriovenous fistula.

A. Remove the tape by pulling from the center of the dressing. B. Clean the wound from the center to the outer edges. C. Moisten the dressing before removal. D. Wear sterile gloves to remove the dressing.

Correct Answer is B

Explanation

A. Incorrect. When removing tape, it is best to pull in the direction of hair growth to minimize skin trauma.
B. Correct. When performing a wet-to-dry dressing change, the wound should be cleaned from the center to the outer edges to prevent introducing contaminants into the wound.
C. Incorrect. Wet-to-dry dressings are typically used to debride wounds by allowing the moist dressing to dry and adhere to wound debris. Moistening the dressing before removal can disrupt this process.
D. Incorrect. Sterile gloves are not typically necessary for performing a wet-to-dry dressing change, as it is a clean technique.

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A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is scheduled for hemodialysis via an arteriovenous fistula in the arm. Which of the following actions should the nurse recommend?

Correct Answer is A

Explanation

A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

Correct Answer is B

Explanation

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