The professional nurse realizes there is both a legal and an ...

[theo]

The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment:
 
  a. Secured
  b. Accessible
  c. Confidential
  d. Documented

Question 2

While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action?
 
  a. Positioning the patient in the dorsal recumbent position with a bed pan
  b. Assisting the patient to the bedside commode
  c. Stopping the enema cleansing and rolling the patient into right-lying Sims' position
  d. Inserting a rectal plug to contain the enema solution

[juicepod]

Answer to Question 1

C
The nurse is legally and ethically obligated to keep information about clients confidential. The nurse may not discuss a client's examination, observation, conversation, or treatment with other clients or staff not involved in the client's care.
The option Secured is not ethically orientated and relates to the written record.
The option Accessible is not ethically orientated and relates to the written record.
The option Documented is not ethically orientated and relates to the written record.

Answer to Question 2

A
Patients with poor sphincter control may not be able to hold in all of an enema solution. Positioning the patient on a bed pan in dorsal recumbent position will allow the nurse to continue to administer the enema. Having the patient get up to toilet is unsafe because the rectal tube can damage the mucosal lining. The purpose of the enema is to promote defecation; stopping it early may inhibit its effectiveness. Use of a rectal plug to contain the solution is inappropriate.