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.

Participate in an in-service about client confidentiality.

Tell the staff members to stop their discussion.

Speak to the staff members in private about client confidentiality.

Answer and Explanation

The Correct Answer is C

a. While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.

b. Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.

c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.

d. Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion

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Correct Answer is D

Explanation

A. Room number of the client:

The room number alone is not sufficient for accurate client identification. Room numbers may change, and multiple clients may share the same room. Relying on the room number alone can lead to errors.

B. Client's telephone number:

The client's telephone number is not typically used as a primary identifier for medication administration. It may be part of the client's record, but it is not the primary means of confirming identity before administering medications.

C. Client's full medical diagnosis:

While the client's medical diagnosis is important for understanding their overall health condition, it is not a primary identifier for medication administration. Diagnoses can be complex and may not be unique to a single individual within a healthcare setting.

D. Name of the client:

Matching the client's name with their identification band or other official records is a crucial step in preventing medication errors and ensuring the right medication is given to the right person.

A. Decreased hemoglobin level B. Increased urinary output C. Decreased BUN level D. Increased weight of 0.91 kg (2 lb)

Correct Answer is B

Explanation

b. Increased urinary output.

Furosemide is a diuretic medication that helps remove excess ﬂuid from the body by increasing urine production and output. In a client with heart failure, one of the indicators that the medication is eﬀective is an increase in urinary output. This can help reduce ﬂuid buildup in the body, which can improve symptoms of heart failure.

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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

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is eﬀective?

Correct Answer is B

Explanation

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