A nurse is reviewing client confidentiality with other staff members.

The nurse should identify that which of the following actions is an example of protecting client confidentiality?

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

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

Discarding worksheets containing client information in a wastebasket

Answer and Explanation

The Correct Answer is A

A. Giving change-of-shift report to a nurse outside the client's room ensures that client information is shared in a private, secure setting, reducing the risk of unauthorized individuals overhearing sensitive information.

B. While sharing information with staff involved in the client's care is generally acceptable, discussing detailed prognosis with assistive personnel (who may not have a need-to-know role) is inappropriate. Confidential information should only be shared with those directly involved in the patient's care as part of the care team.

C. This is a clear violation of confidentiality, as it exposes the client's private health information to anyone who may access the room.

D. This is a breach of confidentiality, as the information could be accessed by unauthorized individuals. The appropriate way to dispose of confidential information is to shred it or return it to the medical record.

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Correct Answer is C

Explanation

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

A. We will keep the client's fluid intake restricted until he is free of pain. B. Expect the stoma to appear pale until healing is complete. C. We need to check the client's urine output every hour. D. Expect the diet’s urine to contain clots for the first 24 hours.

Correct Answer is C

Explanation

Checking the client's urine output regularly is important to monitor kidney function, hydration status, and the proper functioning of the urostomy. This information helps assess the client's overall condition and ensures that urine is flowing adequately. Any significant changes in urine output should be reported to the healthcare team.

Restricting the client's fluid intake until they are free of pain in (option A) is not necessary to be included in the discussion unless specifically ordered by the healthcare provider. Adequate hydration is important for promoting healing and preventing complications.

Expecting the stoma to appear pale until healing is complete in (option B) is not necessary to be included in the discussion. A healthy stoma should have a pink or reddish appearance, indicating good blood supply. A pale stoma may suggest poor blood flow, and this should be assessed and reported to the healthcare provider.

Expecting the client's urine to contain clots for the first 24 hours in (option D) is not included in the discussion after urostomy surgery. Urine containing clots may indicate bleeding or other complications, and this should be promptly evaluated by the healthcare team.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with assistive personnel. Which of the following statements should the nurse include in the discussion?

Correct Answer is C

Explanation

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A nurse is reviewing client confidentiality with other staff members.

The nurse should identify that which of the following actions is an example of protecting client confidentiality?