The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?
Send an email to facility administrators reporting the action.
Warn the colleague that copying health information is unlawful.
Dispose of the copies and continue with client care assignments.
Communicate the colleague’s activities to the unit charge nurse.
The Correct Answer is D
Choice A rationale
Sending an email to facility administrators reporting the action may not be the most immediate or effective way to address the situation. It could delay the necessary intervention and does not ensure that the issue is resolved promptly.
Choice B rationale
Warning the colleague that copying health information is unlawful is important, but it may not adequately address the potential breach of patient privacy and confidentiality. The colleague may already be aware of the laws but still engage in inappropriate behavior.
Choice C rationale
Disposing of the copies and continuing with client care assignments prevents further unauthorized access to patient information but does not address the issue of the colleague’s inappropriate handling of the records. It is essential to report the incident to the appropriate authority for further investigation and follow-up.
Choice D rationale
Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.
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Correct Answer is C
Explanation
Choice A rationale
Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is not appropriate. The UAP should be properly equipped with the correct protective gear before any contact with the client.
Choice B rationale
Instructing the UAP that a standard face mask is sufficient to provide care for the assigned client is incorrect. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.
Choice C rationale
Sending the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N953.
Choice D rationale
Before changing assignments, determining which staff members have fitted particulate filter masks is prudent but not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.
Correct Answer is C
Explanation
Choice A rationale
Releasing the manometer valve immediately is not appropriate as it does not allow for an accurate measurement of systolic blood pressure.
Choice B rationale
Documenting the absence of the radial pulse is not the correct action. The nurse needs to continue the procedure to obtain an accurate systolic blood pressure reading.
Choice C rationale
Inflating the blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse is no longer palpable to ensure an accurate measurement.
Choice D rationale
Recording a palpable systolic pressure of 90 mm Hg is incorrect. The nurse needs to inflate the cuff further to obtain an accurate systolic blood pressure reading.