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.
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Related Questions
Correct Answer is D
Explanation
A. Librium: Librium (chlordiazepoxide) is a benzodiazepine used primarily for anxiety and alcohol withdrawal management. It is not typically prescribed for pain control after surgery and would not be expected in a client using a PCA pump.
B. Disulfiram: Disulfiram is used to deter alcohol consumption by causing unpleasant effects when alcohol is ingested. It has no role in pain management and would not be associated with postoperative care or PCA use.
C. Phenobarbital: Phenobarbital is a barbiturate used to control seizures and sometimes for sedation. It is not prescribed for pain relief and would not be expected for a client recovering from a hysterectomy with a PCA pump.
D. Clonidine: Clonidine can be used as an adjunct to pain management, particularly to enhance the effects of opioids and reduce the amount needed. It can help manage withdrawal symptoms and pain, making it a medication the provider might prescribe alongside a PCA pump.
Correct Answer is B
Explanation
A. Psychologist: A psychologist focuses on mental health assessment and therapy rather than medication management. While they are essential for emotional and psychological support, they are not trained to evaluate or address potential drug interactions in a client's medication regimen.
B. Advanced practice nurse: An advanced practice nurse, such as a nurse practitioner, has the education and authority to assess medication regimens, recognize potential drug interactions, and make adjustments or recommendations. They are well-qualified to manage complex medication issues and collaborate closely with prescribing providers.
C. Patient care technician: Patient care technicians assist with basic care activities such as hygiene, mobility, and vital signs monitoring but do not have the education or licensure required to evaluate medications. They are not involved in clinical decision-making regarding pharmacologic therapy.
D. Social worker: A social worker provides resources for social support, financial assistance, and counseling, but medication management is outside their scope of practice. They are valuable for holistic care but not for assessing or managing drug interactions specifically.
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