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 B
Explanation
The correct answer is choice B: Perform a chart review to gather data about the clients who developed infections.
Choice A rationale: Conducting an in-service on proper catheter insertion and maintenance may be helpful in addressing the issue but should not be the first step.
Choice B rationale: Performing a chart review to gather data about the clients who developed infections is an essential first step. This allows the nurse manager to analyze potential trends or common factors contributing to the infections, which can help identify specific areas for improvement or intervention (NurseLabs, n.d.).
Choice C rationale: Observing each staff nurse perform a urinary catheter insertion could help identify improper techniques that contribute to the infections. However, this is time-consuming and should be done after a chart review has been conducted.
Choice D rationale: Requiring completion of a self-paced instruction program might improve staff knowledge, but it should not be the first action taken by the nurse manager.
In conclusion, the nurse manager should first perform a chart review to gather data about the clients who developed urinary tract infections. This will help identify possible factors contributing to the infections and guide the nurse manager in developing targeted interventions to address the issue.
Correct Answer is B
Explanation
Choice A rationale:
The nurse should not include the client's dressing change schedule in the verbal report when transferring care to the medical-surgical unit. While this information is important for the client's care, it is not a priority for the receiving unit to know during the immediate transfer. Dressing change schedules can vary based on the type of surgery and wound healing progress, and the medical-surgical unit will focus on the client's overall condition.
Choice B rationale:
The client's level of consciousness is a critical piece of information to include in the verbal report when transferring care. Changes in level of consciousness can indicate neurological deterioration or potential complications, especially after a major surgery like open heart surgery. This information helps the receiving nurses monitor the client's condition closely and respond appropriately if any deterioration occurs.
Choice C rationale:
While reporting the client's vital signs from the previous shift is important, it might not be the most relevant information during the immediate transfer from the postoperative unit to the medical-surgical unit. Vital signs can change rapidly, and the receiving nurses will assess the client's current vital signs upon arrival. Therefore, this information is not the priority for the verbal report.
Choice D rationale:
The client's occupation is not a critical piece of information to include in the verbal report during a transfer from the postoperative unit to the medical-surgical unit. The primary focus of the transfer report should be on the client's immediate postoperative condition, potential complications, and any other information directly related to their current medical status.
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