A nurse is working in an agency that uses EHR for documentation.

Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information?

(Select all that apply.).

Use a personal password to access the system and log off when finished.

Share the password with other nurses who need to access the system.

Print out a copy of the client’s record and store it in a locked cabinet.

Report any breaches or attempted breaches of security to the appropriate personnel.

Delete any information that is incorrect or outdated from the system.

Answer and Explanation

Correct Answer : A,D

The nurse should use a personal password to access the system and log off when finished, and report any breaches or attempted breaches of security to the appropriate personnel.

These actions ensure confidentiality and security of the client’s information by preventing unauthorized access and disclosing any violations.

Choice B is wrong because sharing the password with other nurses who need to access the system violates the principle of minimum necessary access, which means that only those who need the information for a specific purpose should have access to it.

Choice C is wrong because printing out a copy of the client’s record and storing it in a locked cabinet creates a risk of loss, theft, or unauthorized disclosure of the paper record. The nurse should avoid printing out electronic health records unless absolutely necessary, and should follow the proper disposal procedures if they do.

Choice E is wrong because deleting any information that is incorrect or outdated from the system may compromise the integrity and availability of the client’s information. The nurse should follow the established policies and procedures for correcting or updating electronic health records, which may include adding an addendum or annotation to the original entry, but not deleting it.

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Correct Answer is C

Explanation

Assess the client’s understanding and readiness for discharge.

This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.

The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.

Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.

The nurse should not threaten or coerce the client to stay in the hospital against his will.

Choice B is wrong because it is not the priority at this time.

The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.

Choice D is wrong because it is not the first action that the nurse should take.

The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.

A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels.It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.

Some of the benefits of cardiac catheterization are:.

• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.

• It can help determine the best treatment plan for the client based on his or her specific condition and needs.

• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.

• It can reduce the need for more invasive surgery or repeated hospitalizations.

A. “The client in room 12 is very demanding and complains a lot.”. B. “The client in room 14 has a wound dressing that needs to be changed at 10 a.m.”. C. “The client in room 16 is allergic to penicillin and sulfa drugs.”. D. “The client in room 18 is a 65-year-old male who had a myocardial infarction yesterday.”.

Correct Answer is B

Explanation

“The client in room 14 has a wound dressing that needs to be changed at 10 a.m.”

This statement is appropriate for handoff communication because it provides relevant and specific information about the patient’s care plan and any pending tasks that need to be completed by the next nurse.

It also allows for the opportunity for discussion and clarification between the nurses.

Choice A is wrong because it is subjective and disrespectful to the patient.

It does not convey any useful information about the patient’s condition, needs, or preferences.

It may also create a negative bias or impression on the next nurse, which could affect the quality of care.

Choice C is wrong because it is not timely or relevant for handoff communication.

The patient’s allergies should be documented in the electronic health record (EHR) and verified with the patient before administering any medications.

It is not necessary to repeat this information during every handoff, unless there is a change or concern.

Choice D is wrong because it is too vague and incomplete for handoff communication.

It does not provide any details about the patient’s current status, vital signs, medications, interventions, or goals.

It also does not indicate any anticipated changes or potential complications that the next nurse should be aware of.

Handoff communication is a critical element of patient safety and continuity of care.

It involves the transfer of essential patient data from one caregiver to another during transitions of care across the continuum.It should be interactive, accurate, concise, and standardized.Some examples of handoff communication tools are SBAR (Situation, Background, Assessment, Recommendations), I PASS the BATON (Introduction, Patient, Assessment, Situation, Safety concerns, Background, Actions, Timing, Ownership, Next), ISHAPED (Introduction, Story, History, Assessment, Plan, Error prevention, Dialogue), and kardex.

These tools help to structure and organize the information exchange between providers and ensure that nothing is missed or misunderstood.

References:.

:12 patient handoff communication tools to know - Becker’s ASC.

:Handoff communication - standardizing nursing protocols.

:Communication Strategies for Patient Handoffs | ACOG.

:8 Tips for High-quality Hand-offs - The Joint Commission.

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A nurse is working in an agency that uses EHR for documentation. Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is giving a change of shift report to the nurse on the next shift. Which of the following statements by the nurse is appropriate for handoff communication?

Correct Answer is B

Explanation

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Which of these statements about documentation are true? (Select all that apply.).

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A nurse is working in an agency that uses EHR for documentation.

Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information?

(Select all that apply.).