nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
Tell the nurse that permission from the risk manager is required to view the client's record.
Remind the nurse that only staff caring for the client may access the client's record.
Complete an incident report about the breach of confidentiality.
Contact facility security to remove the nurse from the unit.
The Correct Answer is B
A. While it is important to restrict access to medical records, it is not solely the risk manager's role to give permission; the policy should be followed regarding patient information access.
B. Reminding the nurse that only those directly involved in the client's care should access their medical record upholds confidentiality and patient privacy standards.
C. Completing an incident report is a more formal step and might be warranted later, but initially addressing the behavior directly is more appropriate.
D. Contacting security would be an extreme response; addressing the situation with the nurse first is typically the best course of action.
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Correct Answer is B
Explanation
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B. Dangling the legs over the side of the bed before standing allows blood pressure to adjust gradually, reducing the risk of orthostatic hypotension.
C. Isometric exercises are beneficial for muscle strength but are not specifically helpful in preventing orthostatic hypotension immediately before standing.
D. Protein intake is essential for healing, but it does not directly prevent orthostatic hypotension.
Correct Answer is A
Explanation
A. Asking the client to explain her feelings shows empathy and encourages open communication. It allows the nurse to understand the client's concerns and address them appropriately.
B. Requesting family participation may be helpful, but it does not address the client’s specific feelings of reluctance.
C. While explaining the importance of participation can be beneficial, it may not address the client's emotional response or specific concerns.
D. Simply telling the client it is safe to touch her ostomy does not address her reluctance or provide emotional support.