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. Powered-standing assist lift: A powered-standing assist lift is appropriate for a cooperative client with upper body strength who is non-weight bearing. It allows the client to participate by supporting themselves with their arms while the device safely moves them from the bed to a chair without bearing weight on their lower extremities.
B. Draw sheet: A draw sheet is typically used for repositioning a client in bed, not for transferring them from bed to chair. It does not provide the mechanical support needed to lift and transfer a non-weight-bearing client safely.
C. Gait belt: A gait belt is useful for clients who can bear weight to some degree and require minimal assistance during transfers. Since this client is non-weight-bearing, a gait belt alone would not provide adequate support and could lead to injury.
D. Full body sling lift: A full body sling lift is used for clients who are non-weight bearing and lack the ability to assist in transfers. Since the client described here is cooperative and has upper body strength, a full sling would not be necessary and may restrict their participation.
Correct Answer is A
Explanation
A. Use a moisture barrier on the client's skin: Applying a moisture barrier cream helps protect the skin from irritation caused by constant exposure to stool and urine. It creates a protective layer that prevents breakdown, reduces friction, and maintains skin integrity in incontinent clients.
B. Clean the client's skin with soap and hot water: Using soap and hot water can strip the skin of natural oils and cause dryness or irritation, which increases the risk of breakdown. Gentle cleansing with mild soap and lukewarm water is recommended instead to preserve skin health.
C. Massage the area around the client's coccyx: Massaging bony prominences can damage fragile tissue and capillaries in older adults, increasing the risk for pressure injuries rather than preventing them. Light touch is appropriate, but firm massage should be avoided in at-risk areas.
D. Limit the client's fluid intake: Restricting fluids can lead to dehydration, concentrated urine, and an increased risk of urinary tract infections. Adequate hydration is essential to support overall health and skin resilience, even when managing incontinence.
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