A charge nurse has assigned a group of clients to a licensed practical nurse (LPN). The charge nurse receives reports from her assigned clients about the LPN's lack of care. Which of the following actions should the charge nurse take?

 

Rationale:

A. When opening a sterile package or tray, the top flap should be opened away from the body to prevent contamination from the nurse’s uniform. Opening the flap toward the body risks breaking sterile technique, which is especially critical during procedures like thoracentesis. This is a break in sterile field, and the nurse manager should intervene immediately to prevent potential infection.

B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.

C.The telephone number is considered an acceptable identifier according to The Joint Commission if it is in the medical record and used in combination with another identifier (like full name or date of birth).

D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.

Rationale:

A. Withholding a dose of narcotic pain medication when there is respiratory depression aligns with nonmaleficence, as it prevents further harm by not exacerbating the client's respiratory issues.

B. Discussing advance directives is important but is more related to autonomy and respect for the client’s wishes rather than nonmaleficence.

C. Providing comfort care is a supportive measure but does not specifically address nonmaleficence in terms of preventing harm.

D. Allowing unlimited visitation respects family wishes but does not directly relate to the principle of nonmaleficence regarding the client’s immediate medical needs.