Nokea
A nurse overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?
- A. Notify the client's provider about the incident.
- B. Instruct the AP to discontinue the conversation.
- C. Complete an incident report about the breach of client confidentiality.
- D. Reassign the AP to other clients on the unit.
Correct Answer: B
Rationale: The correct answer is B: Instruct the AP to discontinue the conversation. The nurse should address the situation immediately by instructing the AP to stop discussing the client's care in a public setting like the cafeteria to maintain client confidentiality. This action prevents further breach of confidentiality and reinforces the importance of respecting privacy. Notifying the provider (A) may be necessary later, but the immediate action should be to stop the conversation. Completing an incident report (C) is important for documentation but is not the first step. Reassigning the AP (D) may not address the root issue of confidentiality breach.
You may also like to solve these questions
A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?
- A. I'm having difficulty climbing the stairs at my house.
- B. I am tired of having pain in my joints all the time.
- C. I will need assistance with bathing.
- D. I need some help planning my meals to maintain my weight.
Correct Answer: C
Rationale: Difficulty with bathing, an activity of daily living, indicates a need for occupational therapy to address functional limitations.
A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?
- A. The nurse puts on a face mask.
- B. The nurse turns her back to the sterile field.
- C. The nurse holds her hands above her waist.
- D. The nurse applies goggles.
Correct Answer: C
Rationale: Holding hands above the waist maintains sterility, as areas below the waist are considered non-sterile.
A nurse is teaching a client about implied consent. Which of the following information should the nurse include in the teaching?
- A. The nurse's signature indicates they witnessed the client's signature.
- B. A client must understand risks and benefits of the proposed treatment.
- C. Nonverbal behavior indicates agreement.
- D. Consent can be verbal or written.
Correct Answer: C
Rationale: Implied consent is inferred from nonverbal actions or circumstances, unlike express consent, which involves explicit verbal or written agreement.
The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. Which of the following people has the legal authority to make this health care decision?
- A. The client
- B. The partner
- C. The provider
- D. The oldest adult child
Correct Answer: A
Rationale: A mentally competent client retains legal authority to make healthcare decisions, despite a durable power of attorney, which only applies when the client is incapacitated.
A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
- A. Activate the fire alarm.
- B. Close the fire doors and the doors to the clients' rooms.
- C. Remove all clients from the unit.
- D. Extinguish the fire.
Correct Answer: A
Rationale: The correct answer is A: Activate the fire alarm. This is the most critical step as it alerts others in the facility to the fire, ensuring swift evacuation and response from the fire department. Closing fire doors (choice B) and removing all clients from the unit (choice C) are important steps but should be done after the fire alarm is activated. Attempting to extinguish the fire (choice D) before ensuring everyone's safety is not recommended as it can put the nurse and clients at risk.