A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse?

A nurse is photocopying their assigned client's diagnostic test results.

An assistive personnel (AP) documents a client's vital signs on the client's paper-based graphic record.

The unit secretary faxes a client's laboratory results to the provider.

An RN stays with a client who is reading the medical records that were requested.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: A nurse is photocopying their assigned client's diagnostic test results.

Choice A rationale: The charge nurse should intervene because photocopying a client's diagnostic test results can pose a potential breach of confidentiality and privacy. Unless there is a specific and authorized reason, personal health information should not be copied or removed from the client's medical record.

Choice B rationale: An assistive personnel (AP) documenting a client's vital signs on the client's paper-based graphic record is a routine task and does not require intervention by the charge nurse.

Choice C rationale: The unit secretary faxing a client's laboratory results to the provider is a standard practice for sharing necessary health information with the care team. No intervention is required.

Choice D rationale: An RN staying with a client who is reading their requested medical records is appropriate. Clients have the right to access their own medical records, and the nurse's presence can help address any questions or concerns the client might have while reviewing their records.

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Correct Answer is C

Explanation

Choice A rationale:

The age of the client might impact the care plan, but it doesn't directly relate to the cost effectiveness of care. Older patients might have different health considerations, but the length of their stay and the services they require play a more significant role in cost evaluation.

Choice B rationale:

While the availability of community support groups can be beneficial for the client's overall well-being and recovery, it doesn't directly contribute to evaluating the cost effectiveness of care. Community support groups are more about psychosocial support than cost.

Choice C rationale:

This is the correct choice. The length of the client's stay directly affects the cost of care. Longer stays often involve more resources, medications, treatments, and staff time, leading to higher costs. Shorter and more efficient stays are generally more cost-effective.

Choice D rationale:

The type of insurance the client carries is relevant to the client's financial responsibility for their care, but it doesn't assist in evaluating the overall cost effectiveness of care. The insurance type might affect reimbursement rates, but it doesn't provide a comprehensive picture of cost efficiency.

A. A client who has a penetrating head injury and respiratory rate of 4/min. B. A client who has a comminuted fracture of the femur. C. A client who has a 15.2-cm (6-in) laceration to the scalp with clotted blood visible. D. A client who has a sucking chest wound.

Correct Answer is D

Explanation

Choice A rationale:

A client who has a penetrating head injury and a respiratory rate of 4/min requires immediate attention due to the critical nature of the head injury and the dangerously low respiratory rate. However, in an emergency situation like this, the priority would be a condition that could be rapidly fatal if not addressed promptly.

Choice B rationale:

A client with a comminuted fracture of the femur has a serious injury that requires assessment and treatment, but it is not an immediately life-threatening condition. It falls lower in the priority compared to conditions that directly impact respiratory and cardiovascular function.

Choice C rationale:

A client with a 15.2-cm laceration to the scalp with clotted blood visible also requires attention, but it is not as time-sensitive as a life-threatening condition. Controlling bleeding and cleaning the wound can be addressed after addressing more critical cases.

Choice D rationale:

Correct. A client with a sucking chest wound has a high risk of tension pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse and compromised circulation. This condition can be rapidly fatal. Immediate intervention is required to seal the wound and prevent further air from entering the pleural space.

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A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse?

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