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

Explanation

C. Epistaxis

Heparin is an anticoagulant medication used to prevent blood clot formation. One of the potential adverse effects of heparin therapy is bleeding. Epistaxis, or nosebleeds, can be a sign of abnormal bleeding and should be reported to the provider for further evaluation and adjustment of the treatment plan if necessary.

Weight gain in (option A) is not a common adverse effect of heparin. Weight gain can be caused by various factors, but it is not directly related to heparin administration.

Bradycardia (slow heart rate) in (option B) is not a common adverse effect of heparin. Bradycardia can be caused by other factors unrelated to heparin therapy and should be evaluated separately.

Anorexia (loss of appetite) in (option D) is not typically associated with heparin therapy. Anorexia can have various causes, but it is not directly linked to heparin administration.

Therefore, the nurse should report the occurrence of epistaxis (option C) to the healthcare provider as a potential adverse effect of heparin therapy in the client.

A. Avoid quoting client comments when documenting. B. Limit documentation to subjective information. C. Document giving a dose of pain medication just prior to administration. D. Document information telephoned in by a nurse who left the unit for the day.

Correct Answer is A

Explanation

Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.

Incorrect:

B- Limit documentation to subjective information: This is an incorrect action to take.

Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.

C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.

D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.

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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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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?