A nurse observes two assistive personnel (AP) discussing a client's information in the facility cafeteria. Which of the following actions should the nurse take?

Remind the AP about maintaining client confidentiality.

Notify the client of the breach of confidentiality.

Notify the ethics committee of the breach of confidentiality.

File an incident report with the risk management department.

Answer and Explanation

The Correct Answer is A

A. Reminding the AP about confidentiality is the appropriate immediate response. The nurse should provide education and reinforce HIPAA regulations to prevent future breaches.
B. Notifying the client is unnecessary and could cause undue distress. The priority is to address the behavior and prevent further violations.
C. Notifying the ethics committee is excessive for a first-time or minor violation. This step may be necessary if breaches continue despite education.
D. Filing an incident report is not required unless the breach has significant consequences. The best first step is direct education.

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Correct Answer is A

Explanation

A. Keeping the umbilical cord area clean and dry helps prevent infection. Washing the base of the cord with water is recommended, while avoiding full immersion in water until the cord falls off.
B. The diaper should be folded down below the cord to prevent moisture buildup and irritation. Covering it can trap moisture and increase the risk of infection.
C. Minor bleeding is not expected when the stump falls off. Persistent or excessive bleeding should be reported to the provider.
D. Petroleum jelly is not recommended for umbilical cord care. The cord should be kept dry to facilitate natural detachment.

A. Varicella B. Influenza C. Hepatitis A D. Rotavirus

Correct Answer is D

Explanation

A. Varicella vaccine is given at 12–15 months and a second dose at 4–6 years. It is not given at 2 months.
B. Influenza vaccine is recommended annually starting at 6 months of age. It is not given at 2 months.
C. Hepatitis A vaccine is given at 12–23 months, with a second dose 6 months later. It is not given at 2 months.
D. Rotavirus vaccine is routinely given at 2 months and again at 4 months (and possibly 6 months depending on the vaccine type). This is the correct answer.

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A nurse observes two assistive personnel (AP) discussing a client's information in the facility cafeteria. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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