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.

Answer and Explanation

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.

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Free Nursing Study Resources

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

Explanation

A. "Apply the transdermal patch to either of the client's forearms" is incorrect. The nurse should avoid applying the patch to areas with excessive hair, irritation, or broken skin. Common areas include the upper torso (e.g., upper arm, chest, or back).

B. "Remove the old transdermal patch before applying a new one" is correct. To prevent overdose or accidental administration of an additional dose, the nurse should always remove the old patch before applying a new one.

C. "Apply the patch to a clean, hairless area of the client's skin" is correct. This ensures better adhesion and absorption of the medication, as hair and dirt can interfere with the patch's effectiveness.

D. "Use sterile gloves to apply and remove transdermal patches" is incorrect. Standard gloves are sufficient for applying and removing transdermal patches, as they do not need to be sterile.

E. "Dispose of old transdermal patches in a childproof container" is correct. Fentanyl patches should be disposed of properly to avoid accidental exposure or ingestion by children or pets. A childproof container ensures safe disposal.

A. Apply an ice pack to the affected extremity for 20 min every 2 hr. B. Massage the affected extremity every 4 hr. C. Administer aspirin for pain. D. Initiate bed rest.

Correct Answer is A

Explanation

A. Apply an ice pack to the affected extremity for 20 min every 2 hr.: Applying ice to the affected extremity can help reduce inflammation and discomfort associated with deep-vein thrombosis (DVT). This method is often recommended to decrease swelling and prevent further complications.

B. Massage the affected extremity every 4 hr.: Massage should be avoided in cases of DVT as it can dislodge the thrombus, leading to a pulmonary embolism or other life-threatening complications.

C. Administer aspirin for pain.: Aspirin is not recommended for clients on anticoagulant therapy, as it can increase the risk of bleeding. Other pain relief options should be considered that do not interact with anticoagulants.

D. Initiate bed rest.: While limited activity is necessary to prevent the risk of embolism, complete bed rest is not typically recommended. Early ambulation (when safe. is often encouraged to prevent complications like venous stasis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Explanation

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