A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted.
Which of the following actions should the nurse take?
Document the event in the client's progress notes.
Submit an incident report to the risk manager.
Inform the client of the APs' actions.
Tell the APs to stop the conversation.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.
Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.
Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.
Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The charge nurse should identify the social worker as appropriate to share client information with when it involves an involuntarily committed school-age client. This choice is correct because sharing information with a social worker who is actively involved in the client's care and has a legitimate need to know is in line with ethical and legal confidentiality requirements. Confidentiality should be maintained to protect the client's privacy, but sharing information with a healthcare team member who needs it to provide appropriate care is acceptable.
Choice B rationale:
Sharing a client's medical information with the client's employer due to concerns about substance use is not appropriate without the client's explicit consent. It is important to respect the client's confidentiality unless there is a legal obligation or a safety concern. In this case, obtaining the client's permission to share such information is crucial.
Choice C rationale:
Sharing a client's medical information with their partner after the client reports intimate partner abuse should be done with caution. While there may be instances where sharing is necessary to ensure the client's safety, it should ideally be done with the client's consent and while involving appropriate authorities. In some jurisdictions, there may be mandatory reporting requirements for domestic violence, but the client's consent should still be sought when possible.
Choice D rationale:
Sharing a client's medical information with a nurse from another unit after the client commits suicide is not appropriate without a legitimate reason, such as continuity of care. In such cases, information sharing should be limited to what is necessary for the provision of care and should be in accordance with facility policies and privacy laws. The primary consideration should be maintaining confidentiality while ensuring the safety and well-being of other patients and healthcare staff.
Correct Answer is D
Explanation
Choice A rationale:
The client does not need an oxygen mask for a low flow rate of 1 to 2 L/min. Oxygen masks are typically used for higher flow rates and may not be comfortable or necessary for a client requiring such a low oxygen flow.
Choice B rationale:
A reservoir bag is not required for a client receiving low flow oxygen at 1 to 2 L/min. Reservoir bags are commonly used with oxygen masks at higher flow rates to ensure a consistent supply of oxygen during inhalation.
Choice C rationale:
Petroleum jelly is not a necessary supply for a client prescribed home oxygen at 1 to 2 L/min. Its use may not be recommended due to the risk of flammability in the presence of oxygen.
Choice D rationale:
The correct choice is D. The client should have a nasal cannula as a supply upon discharge. A nasal cannula is the appropriate delivery device for low flow oxygen therapy at 1 to 2 L/min. It is comfortable and allows for adequate oxygen supplementation for the client.
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