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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Setting target dates for completion is an important step, but it should come after goals and objectives have been established. Goals and objectives provide the foundation for developing a timeline and action plan.
Choice B rationale:
Identifying areas of support is valuable, but it's not the next immediate action after developing the initial plan. Before seeking support, the nurse should clarify the goals and objectives to ensure that the support is aligned with the intended outcomes.
Choice C rationale:
Determining goals and objectives is the next logical step after developing the initial plan. Goals and objectives help guide the committee's work and ensure that the policy revisions are purposeful and aligned with the desired outcomes.
Choice D rationale:
Implementing recommended strategies is a subsequent action that follows the establishment of goals and objectives. Without clear goals and objectives, the strategies might lack direction and cohesiveness.
Correct Answer is B
Explanation
Choice A rationale:
Request crutches from a medical equipment provider. This choice is not appropriate for a client with left-sided weakness due to a stroke. Crutches are primarily used for lower extremity support and would not address the client's mobility and safety needs related to their left-sided weakness.
Choice B rationale:
Advise the client to install grab bars in the bathroom at home. This is the correct choice. Installing grab bars in the bathroom will enhance the client's safety and independence. Left-sided weakness can result in balance issues, and having grab bars near the toilet and in the shower can help prevent falls and provide the client with support while using these facilities. This intervention promotes the client's functional autonomy and reduces the risk of injury.
Choice C rationale:
Encourage the client to allow a home care aide to perform ADLs for them. While it might be necessary for a client with severe disability to receive assistance with Activities of Daily Living (ADLs), the question does not provide enough information to suggest that the client's condition warrants this level of intervention. Encouraging independence is generally preferred to maintain the client's self-esteem and engagement in daily life activities.
Choice D rationale:
Contact hospice to provide follow-up care for the client. Hospice care is intended for clients with terminal illnesses who are in the final stages of life. A client who has had a stroke and is experiencing left-sided weakness does not automatically qualify for hospice care. The client's condition can be managed with rehabilitation and support, and hospice care is not appropriate in this context.
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