The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

Warn the colleague that copying health information is unlawful.

Send an email to facility administrators reporting the action.

Communicate the colleague's activities to the unit charge nurse.

Dispose the copies and continue with client care assignments.

Answer and Explanation

The Correct Answer is C

A. Warn the colleague that copying health information is unlawful:

While informing the colleague about the unlawful nature of copying health information is important, it may not adequately address the potential breach of patient privacy and confidentiality. Additionally, the colleague may be aware of the laws but still engage in inappropriate behavior.

B. Send an email to facility administrators reporting the action:

Reporting the colleague's actions to facility administrators may be necessary, but it may not be the most immediate action to take. Informing the unit charge nurse allows for more immediate intervention and resolution within the unit.

C. Communicate the colleague's activities to the unit charge nurse:

This is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

D. Dispose the copies and continue with client care assignments:

While disposing of the copies may prevent further unauthorized access to patient information, it does not address the issue of the colleague's inappropriate handling of the records. It's essential to report the incident to the appropriate authority for further investigation and follow-up.

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Correct Answer is B

Explanation

A. Switch to a non-rebreather mask:

A non-rebreather mask delivers a higher concentration of oxygen (typically 10-15 L/min) compared to a nasal cannula. However, switching to a non-rebreather mask is a more drastic step that might not be necessary immediately. Other, simpler interventions should be considered first.

B. Verify placement of pulse oximeter:

Before making any changes, it's crucial to verify the accuracy of the oxygen saturation reading. The pulse oximeter might be misplaced or malfunctioning, leading to an inaccurate reading. This is an appropriate first action to ensure the reading is correct before deciding on further interventions.

C. Remove nasal cannula:

Removing the nasal cannula would decrease the client’s oxygenation further, worsening the situation. This is not an appropriate action when oxygen saturation is already low.

D. Increase the oxygen to 3 L/minute:

Increasing the oxygen flow rate is a reasonable intervention to improve oxygen saturation. However, this should typically be done after verifying the accuracy of the oxygen saturation reading. If the reading is correct, this is a valid next step to improve the client’s oxygenation.

A. Auscultate the bowel sounds in all four quadrants. B. Palpate the client's pedal pulse volume bilaterally. C. Determine the elasticity of the client's skin turgor. D. Observe the client's skin and mucous membranes.

Correct Answer is D

Explanation

A. Auscultate the bowel sounds in all four quadrants:

Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.

B. Palpate the client's pedal pulse volume bilaterally:

Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.

C. Determine the elasticity of the client's skin turgor:

Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.

D. Observe the client's skin and mucous membranes:

This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.

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The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Correct Answer is B

Explanation

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is D

Explanation

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