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?

Tell the APS to stop the conversation.

Document the event in the client's progress notes.

Inform the client of the APs' actions.

Submit an incident report to the risk manager.

Answer and Explanation

The Correct Answer is A

A.   Correct. Overhearing private client information being discussed by staff members violates the client's right to privacy and confidentiality. The nurse should address the situation immediately and instruct the assistive personnel to stop the conversation.
B.   Incorrect. While documenting the event in the client's progress notes may be necessary, addressing the inappropriate behavior of the assistive personnel takes precedence.
C.   Incorrect. Informing the client about the conversation is not necessary and may further compromise the client's sense of privacy.
D.   Incorrect. Submitting an incident report to the risk manager might be necessary, but the immediate action should be to stop the conversation and address the breach of confidentiality.

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Correct Answer is B

Explanation

A. Incorrect. When removing tape, it is best to pull in the direction of hair growth to minimize skin trauma.
B. Correct. When performing a wet-to-dry dressing change, the wound should be cleaned from the center to the outer edges to prevent introducing contaminants into the wound.
C. Incorrect. Wet-to-dry dressings are typically used to debride wounds by allowing the moist dressing to dry and adhere to wound debris. Moistening the dressing before removal can disrupt this process.
D. Incorrect. Sterile gloves are not typically necessary for performing a wet-to-dry dressing change, as it is a clean technique.

A. Witness the client signing a consent for transfusion. B. Obtain a large bore IV catheter. C. Ensure two nurses confirm the information on the blood label. D. Ensure the transfusion tubing is flushed with dextrose 5% in water. E. Explain to the client that transfusion reactions are not serious.

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

Explanation

A. Correct. The nurse should witness the client signing a consent form for blood transfusion.
Informed consent is necessary for any medical procedure.
B. Correct. A large bore IV catheter is required for blood transfusion to ensure the smooth flow of blood and prevent clotting.
C. Correct. Two nurses should confirm the information on the blood label, including the client's identification and the blood type, to prevent errors.
D. Incorrect. Transfusion tubing is typically flushed with normal saline before attaching it to the patient. Flushing with dextrose 5% in water is not necessary or recommended.
E. Incorrect. It's important for the nurse to educate the client about potential transfusion reactions, as some reactions can indeed be serious. Providing accurate information helps the client understand the importance of monitoring for any signs of a reaction.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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