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 B

Explanation

A. Assessing whether the expected outcomes were realistic involves evaluating if the goals set in the plan of care were achievable given the client’s condition, resources, and constraints. While this is an important consideration, it is not the immediate next step after reviewing the expected outcomes.
B. After reviewing the expected outcomes, the next critical step is to gather and analyze current client data. This includes assessing the client’s current condition, symptoms, and responses to interventions. By comparing this data with the expected outcomes, the nurse can determine if the goals are being met, if they need adjustment, or if different interventions are required.
C. Reviewing professional standards of care involves understanding the accepted norms and guidelines for nursing practice. While important, this action typically precedes the direct evaluation of care and is part of ensuring that the care plan was developed and implemented according to professional guidelines.
D. Modifying nursing interventions is an action that might be required if the evaluation shows that the expected outcomes are not being met. However, this action is taken after evaluating the effectiveness of the current interventions by comparing client data with expected outcomes.

A. Offer to adjust the height of the walker. B. Explain the need to remove the wheels from the walker. C. Demonstrate more coordinated movement of the legs and walker. D. Encourage the client to continue using the walker as observed.

Correct Answer is A

Explanation

A. The walker should be adjusted to the client's height so that their elbows are slightly flexed when grasping the hand bars. This allows for proper weight-bearing and reduces strain on the shoulders and arms. Using a walker that is the correct height can help to prevent falls by providing better stability and support.
B. Removing the wheels from the walker would make it difficult for the client to use. The wheels are an important feature of a walker, as they allow the client to move more easily.
C. While demonstrating more coordinated movement may be helpful, it's not the most immediate action needed. Adjusting the height of the walker is a more important step to ensure the client's safety and comfort.
D. Encouraging the client to continue using the walker as observed may not be appropriate if the walker is not adjusted to the correct height. A properly adjusted walker is essential for safe and effective mobility.

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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?

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Naxlex Comprehensive Predictor Exams

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct Answer is B

Explanation

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

Correct Answer is A

Explanation

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