The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

Ask the colleague why the action is being performed.

Remind the colleague of information security principles.

Send email to facility administrators reporting the action.

Comment about the action on a staff discussion board.

Answer and Explanation

The Correct Answer is B

A.   While this may provide some insight into the colleague's motivations, it doesn't directly address the issue of patient privacy and confidentiality.
B.   Reminding the colleague of information security principles helps reinforce the importance of maintaining client confidentiality and proper handling of sensitive information. This action promotes awareness and correction of improper practices without escalating the situation unnecessarily.
C.   Reporting the issue to the facility administrators may be necessary if the colleague continues to violate privacy and confidentiality principles. However, it's important to address the issue directly with the colleague first.
D.   Publicly discussing the issue on a staff discussion board could be embarrassing for the colleague and may not be the most effective way to address the problem.

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Correct Answer is A

Explanation

A. This action is appropriate given that the client’s posture is upright and their gait is smooth and steady. If the client demonstrates safe ambulation and is capable of performing ADLs effectively, documenting this observation is crucial for maintaining a record of their functional status.
B. Initiating a fall risk protocol may not be immediately necessary if the client shows a smooth, steady gait and upright posture. However, fall risk assessments are generally based on multiple factors, including history of falls, medication side effects, and environmental hazards.
C. The client’s smooth and steady gait suggests they are ambulating effectively. Teaching the client to shorten their stride is typically advised when there is observed instability or an increased risk of falls.
D. Assessing the client's activity tolerance is a valid consideration, but it may not be the immediate next step if the client’s gait and posture are already observed to be steady and upright.

A. Measure body temperature. B. Administer PRN oxygen. C. Send for chest x-ray. D. Obtain sputum for culture.

Correct Answer is B

Explanation

A. Measuring body temperature is important in assessing the client’s overall condition and identifying a fever, which is common in pneumonia. However, while it provides useful information about the client's status, it is not the most urgent action compared to interventions that could immediately impact the client’s respiratory function or confirm the diagnosis.
B. Administering PRN (as needed) oxygen is crucial if the client shows signs of hypoxia or difficulty breathing. If the client's face appears cyanotic or if they are experiencing respiratory distress, this action should be prioritized to ensure adequate oxygenation.
C. A chest x-ray is essential for diagnosing pneumonia and assessing the extent of lung involvement. However, while it is critical for diagnosis, addressing immediate respiratory needs and symptoms takes precedence.
D. Obtaining sputum for culture is important for identifying the causative organism and guiding antibiotic therapy. However, this action is less urgent than ensuring the client’s immediate respiratory needs are met and confirming the diagnosis through imaging.

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The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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