A charge nurse witnesses assistive personnel failing to follow facility protocol when discarding contaminated lines. Which of the following actions should the nurse take first?

Alert the infection control department

Discuss the issue with the AP

Reinforce facility protocols at the next staff meeting

Notify the unit manager about the incident

Answer and Explanation

The Correct Answer is B

a.   While alerting the infection control department is important, directly addressing the issue with the involved personnel should be the initial action.
b.   Discussing the issue with the assistive personnel (AP) allows for immediate clarification of the protocol and provides an opportunity to correct the behavior.
c.   Reinforcing facility protocols at a staff meeting may be necessary but should not be the first step when immediate action is required.
d.   Notifying the unit manager is important, but addressing the issue with the AP directly is the first step in resolving the situation and preventing future occurrences.

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Correct Answer is B

Explanation

a. This response may come across as dismissive of the client's concerns and may not address the client's anxiety about pain adequately.
b. This response validates the client's feelings, acknowledges that it's okay to change their mind, and opens the door for further discussion or exploration of alternatives.
c. This response may sound accusatory and may not effectively address the client's immediate concerns.
d. This response does not address the client's worries about pain and may minimize their concerns.

A. Ask the client if she would like a sedative to help her relax B. Inform the client that she cannot leave without a discharge prescription from the provider C. Have the client sign the Against Medical Advice form D. Assign a security officer to the client's room until the provider can speak with the client

Correct Answer is C

Explanation

. Inform the client that she cannot leave without a discharge prescription from the provider

Rationale:
a. Offering a sedative may not address the client's concerns and is not an appropriate response to the situation.
b.Inform the client that she cannot leave without a discharge prescription from the provider. Clients have the right to leave against medical advice; informing them otherwise infringes on their rights.

C Have the client sign the Against Medical Advice form. This action respects the client's autonomy while ensuring documentation of her decision to leave against medical advice, which protects both the client and healthcare facility legally.

d. Assigning a security officer to the client's room may escalate the situation unnecessarily. The focus should be on communication and education.

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A charge nurse witnesses assistive personnel failing to follow facility protocol when discarding contaminated lines. Which of the following actions should the nurse take first?

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