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 A

Explanation

A. When the client voided following catheter removal:

This information is crucial because it indicates the return of the client's ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.

B. Color of the urine during catheter removal:

While the color of the urine during catheter removal may provide some insight into the client's urinary condition, it is not as critical as knowing when the client voided after catheter removal to assess urinary function.

C. Time of the last dose of IV antibiotic administration:

While the timing of the last dose of IV antibiotic administration is important for managing the client's urinary tract infection, it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.

D. Intake and output reports for the previous shift:

Intake and output reports are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.

A. Use positive reinforcement to affirm that the procedure is being performed correctly. B. Remind the UAP to lubricate the thermometer before gently inserting in the ear. C. Demonstrate the correct technique for pulling the client's auricle down and back. D. Advise the UAP to hold the thermometer securely in place for a full three minutes.

Correct Answer is A

Explanation

A. Use positive reinforcement to affirm that the procedure is being performed correctly:

Use positive reinforcement to affirm that the procedure is being performed correctly: This is correct. Positive reinforcement is important for encouraging and motivating staff, it should be used appropriately. In this case, the UAP isperforming the procedure correctly

B. Remind the UAP to lubricate the thermometer before gently inserting it in the ear:

Lubrication is not typically necessary for tympanic thermometers. However, the primary issue in this scenario is the incorrect technique for positioning the client's auricle, so reminding about lubrication is not the most relevant intervention.

C. Demonstrate the correct technique for pulling the client's auricle down and back:

This is incorrect action to take. The UAP is using the correct technique.

D. Advise the UAP to hold the thermometer securely in place for a full three minutes:

Tympanic thermometers typically provide rapid temperature readings within a few seconds, so holding the thermometer in place for three minutes is unnecessary and may cause discomfort to the client. Additionally, the primary issue in this scenario is the incorrect technique for positioning the client's auricle, not the duration of thermometer insertion.

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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

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

Correct Answer is A

Explanation

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to Insert the thermometer. Which action should the nurse implement?

Correct Answer is A

Explanation

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