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?

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

Discarding worksheets containing client information in a wastebasket.

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

Choice A rationale: Writing a client's diagnosis on the message board in the client's room can expose sensitive information to anyone who enters the room, which compromises client confidentiality.

Choice B rationale: Discarding worksheets containing client information in a wastebasket is not secure and can lead to unauthorized access to confidential information.

Choice C rationale: Giving change-of-shift report to a nurse outside the client's room protects client confidentiality by ensuring that sensitive information is shared only with authorized personnel in a private setting.

Choice D rationale: 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 C

Explanation

Choice A rationale:

Avoiding the use of draw sheets for repositioning is not a direct intervention for managing urinary incontinence. Draw sheets are typically used for repositioning and preventing pressure injuries. Managing urinary incontinence involves strategies such as toileting schedules, absorbent products, and perineal care.

Choice B rationale:

Limiting periods of sitting in a chair to 4 hours is a general guideline for preventing pressure ulcers in individuals with limited mobility, but it is not specific to managing urinary incontinence. Clients with urinary incontinence may need to sit in chairs for extended periods, and it is essential to address incontinence management separately.

Choice C rationale:

Using a no-rinse perineal cleanser after incontinence is an appropriate intervention for maintaining skin hygiene and preventing irritation in individuals with urinary incontinence. No-rinse cleansers are designed to clean the perineal area without the need for rinsing, making them convenient for incontinence care. Choice D

A. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. B. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. C. A nurse discovers that a client's family member has administered a PCA dose. D. A nurse observes a client vomiting after receiving an oral pain medication.

Correct Answer is B

Explanation

Choice A rationale:

Removing wrist restraints one at a time from a calm client, while not following the recommended two-person verification process, is a potential safety concern but may not require an incident report. However, it should be addressed according to the facility's policies and procedures.

Choice B rationale:

An electronic IV pump delivering twice the prescribed amount of fluid is a critical incident that should be reported immediately via an incident report. Such errors can have serious consequences for the patient and may require immediate intervention.

Choice C rationale:

Discovering that a client's family member administered a PCA dose is also a significant event that should be reported via an incident report. PCA (Patient-Controlled Analgesia) dosing should only be administered by healthcare professionals to ensure safe and accurate medication delivery.

Choice D rationale:

Observing a client vomiting after receiving an oral pain medication should be addressed and documented in the patient's medical record as a change in the patient's condition, but it may not necessarily require an incident report unless there are extenuating circumstances or complications.

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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

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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?