A nurse overhears two assistive personnel (AP) in the cafeteria discussing a client's care during lunch. Which of the following actions should the nurse take?

Ask the APs to discontinue the conversation.

Inform the client what has occurred.

Notify the client's provider.

Schedule a disciplinary conference for the APS.

Answer and Explanation

The Correct Answer is A

Ask the APs to discontinue the conversation:

This is the most appropriate immediate action. Discussing a client's care in a public area violates the principle of patient confidentiality. The nurse should intervene promptly and ask the assistive personnel to stop the conversation.

Inform the client what has occurred:

While transparency with the client is important, it may not be the first action to take in this situation. The priority is to address the breach of confidentiality by stopping the conversation.

Notify the client's provider:

Notifying the client's provider is not the initial action to take in this situation. First, the nurse should address the immediate issue by stopping the inappropriate conversation. The provider may be informed later, if necessary.

Schedule a disciplinary conference for the APs:

Scheduling a disciplinary conference is a step that may be taken after addressing the immediate issue. The priority is to stop the inappropriate conversation and address confidentiality concerns before considering disciplinary actions.

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Correct Answer is ["A","C","D"]

Explanation

Ensure the client wears nonskid slippers when walking around the house.

Explanation: Nonskid slippers provide better traction and stability, reducing the risk of slipping.

B.Attach full-length side rails to the client's bed.

Explanation: Side rails can pose a risk of entrapment and may not prevent falls. The use of side rails is associated with safety concerns, and their use should be carefully evaluated.

C.Install a raised toilet seat in the client's bathroom.

Explanation: A raised toilet seat makes it easier for the client to sit down and stand up, reducing the risk of falls in the bathroom.

D.Encourage an annual review of the medications the client is taking.

Explanation: Medication reviews help identify drugs that may increase the risk of falls or interactions that could affect balance or cognitive function.

E.Place throw rugs on uncarpeted floors in the client's home.

Explanation: Throw rugs can be tripping hazards, especially for older adults with mobility issues. It's safer to have clear, unobstructed pathways in the home.

A. The client's blood pressure was recorded at 0730 and 1130. B. The client's pain medication was administered twice during this shift. C. The client's enteral feeding bag needs to be changed at 2200. D. The client received a bath and backrub.

Correct Answer is A

Explanation

A. The client's blood pressure was recorded at 0730 and 1130.

In a change-of-shift report, it is important to communicate vital signs, especially changes in the client's condition. Recording the blood pressure at different times during the shift helps the oncoming nurse understand the client's cardiovascular status and identify trends or potential issues.

B. The client's pain medication was administered twice during this shift:

While medication administration is important information, specifying the number of times pain medication was administered may be less relevant in a brief change-of-shift report. It's more critical to communicate the client's pain level, response to medication, or any concerns related to pain management.

C. The client's enteral feeding bag needs to be changed at 2200:

While enteral feeding is an essential aspect of care, the timing of the feeding bag change may not be as crucial in a change-of-shift report. Instead, it would be more pertinent to communicate any issues related to the client's tolerance of feeding, any changes in feeding rate, or signs of intolerance.

D. The client received a bath and backrub:

Personal care activities, such as a bath and backrub, are essential components of nursing care, but they may be less critical in a change-of-shift report unless there are specific concerns related to the client's skin condition or overall well-being. More emphasis should be placed on clinical assessments and changes in the client's condition.

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A nurse overhears two assistive personnel (AP) in the cafeteria discussing a client's care during lunch. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is A

Explanation

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