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 C
Explanation
A. Holding the sterile solution bottle over the field is acceptable as long as it is not placed on the field.
B. Placing unnecessary sterile items does not contaminate the field, though it may clutter the workspace.
C. Allowing sterile forceps to rest in a container of sterile water compromises the sterility of the field, as the water can act as a medium for contamination.
D. The handle of sterile scissors resting close to the field edge is acceptable if it is not in contact with the non-sterile area.
Correct Answer is D
Explanation
A. Postponing the procedure could put the client’s health at risk.
B. If the client cannot provide informed consent due to a developmental disability, they are not considered able to consent independently.
C. The provider does not sign the consent form on behalf of the client in this situation; rather, implied consent is used in emergencies.
D. In an emergency situation where delaying treatment could harm the client, implied consent allows for immediate life-saving procedures without waiting for guardian consent.