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 AP's actions.
Submit an incident report to the risk manager.
The Correct Answer is A
Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.
When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.
The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Albuterol is a bronchodilator medication that is commonly delivered through a metered-dose inhaler (MDI) to treat asthma and other respiratory conditions. Proper inhaler technique is crucial for effective delivery of the medication to the lungs.
Option (a) is incorrect because the client should actually tilt their head back slightly and breathe out fully before inhaling the medication.
Option (b) is incorrect because the client should take a slow, deep breath in while depressing the canister once.
Option (d) is incorrect because the client should hold their breath for 10 seconds after inhaling the medication to allow it to reach the lungs.
Therefore, the correct instruction for the nurse to include in the teaching is to instruct the client to close their mouth around the mouthpiece of the inhaler to ensure that the medication is delivered directly to the lungs.

Correct Answer is C
Explanation
This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.
The following examples may not require an incident report:
A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.
A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.
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