A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
Report the incident to the charge nurse.
Tell the staff members to stop their discussion.
Participate in an in-service about client confidentiality.
Speak to the staff members in private about client confidentiality.
The Correct Answer is B
A. Reporting the incident to the charge nurse is incorrect as the first step. While this action may be necessary if the issue continues, the immediate step should be to intervene directly to stop the conversation and prevent further breach of confidentiality.
B. Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client’s medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client’s privacy is respected.
C. Participating in an in-service about client confidentiality is incorrect as the first step. While in-service education on client confidentiality is important, it is not an immediate action to address a current breach of confidentiality.
D. Speaking to the staff members in private about client confidentiality is incorrect. While private conversation is important to address the issue further, the first action is to stop the conversation immediately to prevent any further privacy violations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.
B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.
C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.
D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.
Correct Answer is C
Explanation
A. Wearing a mask by family members is not typically necessary at home once the client is on effective treatment for tuberculosis and the infectious period has passed. The client should avoid public places and limit contact with vulnerable individuals, but family members do not need to wear masks at home after the initial treatment phase.
B. Long-term medication is required for tuberculosis, but not for the rest of the client’s life. Treatment usually lasts for 6-9 months, not a lifetime. Adherence to the medication regimen is crucial to prevent relapse or resistance.
C. Throwing away used tissues in a closed plastic bag is correct. This is a key infection control measure to prevent the spread of tuberculosis through respiratory droplets. Used tissues should be discarded in a closed, lined container, and the client should practice good hygiene.
D. No longer infectious after 30 days of treatment is incorrect. A client with tuberculosis may remain infectious until they have completed several weeks of treatment and show improvement. Typically, a negative sputum culture is used to confirm the client is no longer infectious.
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