A nurse on a unit is assisting with the care of a group of clients. Which of the following observations by the nurse requires intervention?
A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for.
A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use.
A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care.
A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report.
The Correct Answer is C
A. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: This is appropriate documentation practice. Nurses are responsible for documenting client information in the EMR when they provide direct care, ensuring accurate and timely records.
B. A nursing colleague printing material that does not contain identifiable information from a client's electronic medical record (EMR) for professional use: If no identifiable client information is included, and it is for professional, educational, or training purposes, this action is acceptable and does not violate confidentiality.
C. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care: Discussing confidential client information with staff not directly involved in the client's care is a violation of HIPAA and breaches client privacy. Only staff responsible for the client's care should access or discuss their health information.
D. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: This is appropriate because handoff reports ensure continuity of care. Discussing necessary client information with the next caregiver is essential for safe, effective client management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Apply the gown before the gloves: The gown must be applied before donning gloves to ensure that the gown fully covers the arms and torso, providing a protective barrier against contamination. Gloves are then pulled over the gown cuffs to maintain a proper seal and reduce the risk of pathogen exposure, especially with infections like Clostridium difficile.
B. The gown with the gloves on: Wearing the gown after gloves compromises the sterile barrier, allowing pathogens to contact the skin or clothing. This technique increases the risk of contamination because the gloves may not completely cover or seal the gown’s cuffs properly, which is critical in preventing the spread of infection.
C. Tuck the glove cuffs under the gown sleeves: Gloves should not be tucked under gown sleeves. Instead, gloves should cover the gown cuffs, creating a continuous protective layer. Tucking gloves under the gown can leave the wrists exposed and vulnerable to contamination, particularly when caring for clients with highly transmissible infections.
D. Push the gown sleeves up to the elbows: Pushing the sleeves up to the elbows defeats the protective purpose of the gown. It exposes the forearms to potential pathogens and bodily fluids, increasing the risk of infection transmission to both the nurse and other clients, especially when dealing with spore-forming bacteria like Clostridium difficile.
Correct Answer is A
Explanation
A. "I will ask to have you assigned to a female nurse.": Respecting the client’s preference supports her autonomy, comfort, and dignity. Offering to accommodate her request shows sensitivity to her personal, cultural, or religious needs and helps maintain a trusting nurse-client relationship.
B. "I will get a female assistive personnel to provide your bath.": While providing a female assistive personnel for bathing might address part of the concern, it does not fully meet the client's expressed preference for all aspects of nursing care to be provided by a female nurse.
C. "You will need to speak with the nurse manager about this.": Asking the client to manage the reassignment request herself can seem dismissive. It is the nurse’s responsibility to advocate for the client and initiate steps to meet her needs whenever possible.
D. "I care for other female clients and they do not mind having a male nurse.": Comparing the client’s feelings to those of others invalidates her concerns and does not demonstrate respect for her individual preferences, which is essential in client-centered care.
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