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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

a. Recommend the AP come back later when the record is available:

This option delays the documentation process unnecessarily and may inconvenience the AP.

It doesn't address the issue of maintaining patient confidentiality and accurate documentation.

b. Log out so the AP can log in to document the vital signs:

This is the correct choice as it ensures that each individual's documentation is attributed to the correct user.

It maintains patient confidentiality and adheres to HIPAA regulations.

It allows the AP to complete their task efficiently while preserving the integrity of the electronic record.

c. Offer to chart the vital signs for the AP:

This option involves the nurse taking over the responsibility of documenting the vital signs for the AP, which could lead to confusion and potential errors.

It's not the most appropriate solution as it may not be feasible for the nurse to document the vital signs accurately without directly measuring them.

d. Allow the AP to document the vital signs prior to logging out:

Allowing the AP to document vital signs under the nurse's login compromises the integrity of the electronic record and violates HIPAA regulations.

It's not an acceptable practice as it can lead to inaccuracies in the documentation and compromises patient confidentiality.

A. Green B. Yellow C. Black D. Red

Correct Answer is C

Explanation

a. Green:

Green triage tags are typically used for "walking wounded" or patients with minor injuries who can wait longer for treatment. These patients are considered to have non-life-threatening injuries and can be managed after more critical patients have been stabilized.

b. Yellow:

Yellow triage tags are used for patients with moderate injuries who require medical attention but are not in immediate danger of death. These patients may have significant injuries that require timely treatment but do not have life-threatening conditions.

c. Black:

The black tag is used for patients who are not expected to survive due to severe injuries or critical conditions. In the case of full-thickness burns covering a large percentage of the body (such as 72%), the patient’s prognosis is poor, and immediate care resources should be allocated to those with a higher chance of survival.The black tag indicates that the patient’s injuries are incompatible with life, and comfort measures may be provided, but resuscitation efforts are not a priority.

d. Red:

Red triage tags are used for patients with life-threatening injuries who require immediate medical attention to survive. These patients have critical conditions that require rapid assessment, stabilization, and treatment to prevent further deterioration and improve outcomes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse has just completed assessment charging on the electronic record for an assigned client. An assistive personnel who just measured the client’s vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full thickness burns on 72% of his body?

Correct Answer is C

Explanation

A nurse is preparing to delegate bathing and turning of a newly admitted client who has end- stage bone cancer to an experienced assistive personnel. Which of the following assessments should the nurse make before delegating care?

A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? SATA

A charge nurse making rounds observes that an assistive personnel has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report?

A nurse is receiving a verbal prescription from the provider for a client who is having increased pain. The nurse should transcribe which of the following prescription in the client’s medical record?

A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take?

Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan?

A nurse is teaching a newly licensed nurse about delegating tasks to assistive personnel. Which of the following statements should the nurse make?