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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tachypnea. Rapid breathing is associated with diabetic ketoacidosis (DKA) rather than mild hypoglycemia.
B. Ketonuria. The presence of ketones in the urine occurs with prolonged hyperglycemia and DKA, not with hypoglycemia.
C. Warm skin. Hypoglycemia typically causes cool, clammy skin due to sympathetic nervous system activation, not warmth.
D. Nervousness. Low blood glucose triggers the release of epinephrine, leading to symptoms such as nervousness, tremors, and sweating.
Correct Answer is B
Explanation
A. Allergic. Symptoms of an allergic reaction to a blood transfusion typically include itching, rash, and hives rather than chills, headache, or low-back pain.
B. Acute hemolytic. This reaction occurs when the client receives incompatible blood, leading to red blood cell destruction. Symptoms include chills, headache, low-back pain, chest tightness, hypotension, and fever.
C. Bacterial. A bacterial transfusion reaction is usually caused by contaminated blood products and presents with fever, chills, hypotension, and possible sepsis. The described symptoms suggest a different reaction.
D. Febrile nonhemolytic. This reaction is more common and presents with fever, chills, and headache but does not typically include low-back pain or chest tightness, which are more indicative of an acute hemolytic reaction.
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