The nurse is conducting a staff in-service on client privacy. Which of the following actions would the nurse recognize as violations of client confidentiality? Select all that apply.
- A. Accessing a co-worker's address in their medical record to surprise them with a birthday gift.
- B. Reviewing a client's prescriptions with a student nurse who is assigned to the client.
- C. Looking up the medical information of a friend from a previous stay, even with their permission.
- D. Viewing a friend's medical record because you are listed as their power of attorney.
- E. Walking away from a computer terminal without securing it, even if the monitor is turned off.
Correct Answer: A, C, E
Rationale: Accessing a co-worker’s record for personal reasons (A), viewing a friend’s past record without current need (C), and leaving an unsecured computer (E) violate HIPAA confidentiality rules. Reviewing prescriptions with an assigned student (B) is educational, and viewing as power of attorney (D) may be authorized.
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The nurse is caring for a client who has been brought to the emergency department after a severe car accident. They require immediate life-saving surgery; however, they are unconscious and unable to consent to the operation. Which of the following is the best course of action?
- A. Ask a friend who was with the client to sign the consent form.
- B. Attempt calling a family member to obtain consent.
- C. Call the on-staff nursing supervisor and request a court order for the surgery.
- D. Immediately transport the client to the operating department without obtaining consent.
Correct Answer: D
Rationale: Implied consent applies for unconscious clients needing life-saving surgery (D), allowing immediate transport to the operating room. Friends (A) cannot legally consent, family contact (B) delays care, and court orders (C) are unnecessary in emergencies.
The nurse is caring for the following assigned clients. It would be a priority for the nurse to assess the client
- A. being evaluated for chest pain and requesting an antacid for indigestion.
- B. reporting nervousness following the administration of albuterol.
- C. requesting pain medication for their chronic knee and back pain.
- D. awaiting discharge teaching on their insulin pump and glucometer.
Correct Answer: A
Rationale: Chest pain with indigestion (A) may indicate a cardiac event, requiring immediate assessment to rule out myocardial infarction. Nervousness from albuterol (B) is a common side effect, chronic pain (C) is less urgent, and discharge teaching (D) can wait.
The infection control nurse delegates tasks to staff to reduce hospital-acquired infections. Which task would be appropriate to delegate to the unlicensed assistive personnel (UAP)?
- A. Educate staff members on actions to reduce central line-associated bloodstream infections
- B. Demonstrating correct handwashing techniques to visitors
- C. Restocking personal protective equipment (PPE)
- D. Screening visitors for respiratory infections
Correct Answer: C
Rationale: Restocking PPE (C) is a non-clinical task within the UAP’s scope. Educating staff (A), demonstrating handwashing (B), and screening visitors (D) require clinical judgment or training, inappropriate for UAPs.
The nurse is teaching a leadership and management course and is discussing client referrals. Which of the following statements best describes the purpose of referrals?
- A. Allows the nurse to demonstrate their leadership abilities.
- B. Care is appropriately routed to an individual or discipline.
- C. Ensures that care is unilateral and cost-effective.
- D. Focuses on empowering the client's decision making.
Correct Answer: B
Rationale: Referrals (B) ensure care is directed to the appropriate specialist or discipline to meet the client’s needs effectively. Demonstrating leadership (A) is secondary. Referrals do not ensure unilateral care (C) and are not primarily about client empowerment (D), though they may support it.
The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who
- A. is repeatedly washing their hands.
- B. talking over others during group therapy.
- C. yelling and shouting at others.
- D. is voluntarily admitted and requesting discharge.
Correct Answer: C
Rationale: Yelling and shouting at others (C) indicates potential agitation or safety risk, requiring immediate follow-up to de-escalate and ensure unit safety. Hand washing (A), interrupting therapy (B), and discharge requests (D) are less urgent.
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