Question 1

A nurse is enrolled in an orientation program regarding clients' rights, confidentiality, and ethical practices in nursing. Which of the following situations is an example of a breach of confidentiality?

A)Release of laboratory results to the client via an encrypted electronic email.
B)Disclosing information for reimbursement of hospital payment.
C)Disclosing the client's disease prognosis to the estranged spouse.
D)Using a reference number to replace the client's name in the medical record.

Disclosing the client's disease prognosis to the estranged spouse.

Accepted Answer

A breach of confidentiality is defined as disclosure of information to a third party without the prior consent of the client or by court order. The medium of disclosure is irrelevant, that is why special security measures, such as encryption and password-protected electronic transfer should be used. Under HIPAA (Health Insurance Portability Accountability Act), covered entities are permitted to release information only to facilitate payment and treatment. This act also provides guidelines for safeguarding the client's privacy through the use of reference numbers or codes.

Question 2

A nurse is caring for a MRSA-colonized client. As the nurse develops the client's care plan, the nurse should take note of the following precautions except:&#10;A)Use of dedicated-client equipment&#10;B)Removal of gloves and gown before leaving the client's room&#10;C)Considering routine waste from the client's room infectious&#10;D)Instruments used for dressing changes are not transferred to another client

Accepted Answer

The nurse keeps in mind that routine waste from the client's room is considered dirty, not infectious. MRSA is transmitted through direct contact or through droplet secretions.

Question 3

A nurse is caring for a female client who sustained second- to third-degree burns. Reverse-protective isolation techniques are implemented. The nurse maintains reverse isolation by which of the following interventions?

A)Perform surgical handwashing before entering the client's room
B)Place the client in a single room maintained under positive pressure
C)Using sterile sheets
D)Using a sterile-type mask on entering the room

Place the client in a single room maintained under positive pressure

Accepted Answer

The client should be placed in a single room maintained under positive pressure. A positive pressure room keeps the flow of air out of the room to protect the client from contaminants. The nurse must wash her hands before entering the room; surgical hand washing is not necessary. Sterile sheets are more appropriate for clients with immunosuppression. A non-sterile type mask must be worn on entering the room.

Question 4

When draining a client's ileostomy bag and changing the dressings, the nurse should use which of the following protective measures?&#10;A)Sterile gloves, sterile mask, gown&#10;B)Double gloves, goggles, mask, gown&#10;C)Goggles, gown, booties and mask&#10;D)Sterile and clean gloves, mask, gown

Accepted Answer

Standard precautions needed when caring for an ileostomy include clean gloves, mask, and gown when draining the bag, and a sterile glove when changing the dressing. The nurse should change gloves in between the two procedures to avoid contact with body fluids. Goggles are used if the procedure would likely generate a splash or spray of body fluids.

Question 5

A nurse is assigned in the triage area of the emergency department. The nurse is assigned to care for a three-year-old child complaining of severe abdominal pain. Further assessment shows abdominal distension, shortness of breath, and lethargy. What is the appropriate category for this child?

A)Red
B)Green
C)Yellow
D)Black

Accepted Answer

This child's condition is categorized as RED, which requires the highest priority. This category is given to patients with life-threatening conditions, such as airway obstruction, decreased level of consciousness, and massive or uncontrolled bleeding. The GREEN category has the lowest priority. YELLOW is reserved for clients with serious but not life-threatening conditions. The BLACK category is given to deceased or non-salvageable clients.

Deck 5: Safety