A nurse overhears two assistive personnel discussing a client’s care in the cafeteria. Which of the following actions should the nurse take?

Complete an incident report about the breach of client confidentiality

Reassign the AP to other clients on the unit

Instruct the AP to discontinue the conversation

Notify the client’s provider about the incident

Answer and Explanation

The Correct Answer is C

a. Complete an incident report about the breach of client confidentiality:

While documenting the incident is important, completing an incident report alone may not address the immediate need to stop the breach of confidentiality.

b. Reassign the AP to other clients on the unit:

Reassignment may be considered after addressing the immediate issue, but it doesn't directly address the inappropriate conversation.

c. Instruct the AP to discontinue the conversation:

This is the correct immediate action. The nurse should intervene and instruct the assistive personnel to stop discussing the client's care in a non-secure location like the cafeteria.

d. Notify the client’s provider about the incident:

While notifying the client's provider may be necessary in certain situations, the immediate concern is to stop the breach of confidentiality and address the inappropriate conversation.

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Correct Answer is D

Explanation

a. Wears clean gloves to remove the soiled dressing: This action is appropriate. Wearing clean gloves helps maintain aseptic technique and prevents contamination of the wound during dressing removal.

b. Uses slow, continuous pressure to flush the wound: This action is appropriate. Using slow, continuous pressure helps ensure effective irrigation of the wound without causing trauma to the tissue.

c. Places the syringe tip with angiocatheter 2.5 cm (1 in) above the open wound bed: This action is appropriate. Maintaining the appropriate distance ensures that the irrigation solution reaches the wound bed effectively without causing unnecessary trauma.

d. Opens irrigation supplies before removing the soiled dressing: This action is not appropriate. Opening irrigation supplies before removing the soiled dressing increases the risk of contamination. The nurse should first remove the soiled dressing using aseptic technique and then prepare the irrigation supplies.

A. Include the time the medication error occurred in the report B. Identify the medication name and dosage administered to the client in the report C. Make a copy of the incident report for personal record keeping D. Place a copy of the completed report in the client’s medical record E. Obtain an order from the client’s provider to complete the report

Correct Answer is ["A","B"]

Explanation

A.Documenting the time of the error is important for accurately recording when the event happened and for assessing potential impacts on patient care.

B.Including specific details about the medication involved and the dosage is crucial for understanding the nature of the error and for evaluating its potential consequences.

C.Incident reports are confidential and should not be copied for personal records. They are used for internal review and quality improvement purposes and should be handled according to the facility's policies on confidentiality.

D.The incident report should not be placed in the client’s medical record. It is a separate document intended for internal use and quality improvement, not part of the client’s clinical record.

E.No order from the provider is needed to complete an incident report. The report is a standard procedure for documenting and analyzing errors and is part of the facility's protocol for ensuring patient safety.

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A nurse overhears two assistive personnel discussing a client’s care in the cafeteria. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is ["A","B"]

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