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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
B. Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.
C. Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.
D. Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.
Correct Answer is C
Explanation
A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
B. Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
C. Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D. Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.