Scenario:
A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit.

Exhibits

The client receiving epidural anesthesia would be at risk for developing

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due to

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.

Choice A rationale

Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan.

Choice B rationale

Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach.

Choice D rationale

Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications.

Choice C rationale

Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment.

Choice E rationale

Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.

Choice A rationale

EMR safeguards are designed to protect patient privacy and ensure that only authorized personnel involved in the direct care of the client have access to their medical records. Access controls and audit trails are implemented to prevent unauthorized access and maintain confidentiality. These safeguards comply with healthcare regulations and standards, ensuring that patient information is secure and only accessed when necessary for medical care purposes.

Choice B rationale

Patient confidentiality and privacy are fundamental principles in healthcare. Before any information can be shared by the nurse, the patient's permission must be obtained. This consent ensures that the patient's rights and autonomy are respected, and their personal health information is not disclosed without their explicit approval. Sharing medical information without consent can lead to legal and ethical violations.

Choice C rationale

Encouraging the friend to share her concerns with her daughter and other family members promotes open communication and supports the patient's involvement in their care decisions. However, this choice does not directly address the nurse's responsibility to maintain patient confidentiality and adhere to legal and ethical guidelines regarding access to medical records. While it is a supportive action, it does not replace the need to obtain the patient's consent.

Choice D rationale

Reviewing the EMR without the patient's consent violates client confidentiality and is both legally and ethically prohibited. Healthcare providers must adhere to strict confidentiality standards to protect patient information and maintain trust. Unauthorized access to medical records can result in legal consequences and breaches of professional ethical standards.

Choice E rationale

EMR tracking systems monitor and log access to patient records, ensuring that any attempts to access information are recorded and can be audited. These tracking mechanisms alert the hospital information systems of unauthorized access attempts, providing an additional layer of security and accountability. This helps prevent unauthorized access and ensures that patient confidentiality is maintained.