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 A

Explanation

a. Decreased level of consciousness is a critical finding in a client with meningitis and may indicate worsening intracranial pressure or neurological deterioration, requiring immediate intervention.
b. While an increased temperature may indicate infection, it is not as immediately concerning as a decreased level of consciousness in a client with meningitis.
c. A generalized rash over the trunk may be present in some types of meningitis, but it is not as immediately urgent as a decreased level of consciousness.
d. Photophobia (sensitivity to light) is a common symptom of meningitis but may not require immediate intervention unless accompanied by other concerning neurological findings such as a decreased level of consciousness.

A. Whether the client understands the risk of refusing the procedure B. Whether the partner is the client's durable power of attorney for health care C. Whether the client's refusal is based on a religious belief D. Whether the facility ethics committee reaches a consensus on the case

Correct Answer is A

Explanation

A: The autonomy of the patient is paramount in medical ethics. If the client understands the risks and still refuses the procedure, their choice must be respected. It is a fundamental right for patients to make informed decisions about their own healthcare.

B: While a durable power of attorney for health care is crucial when a patient is incapacitated, it does not override the wishes of a competent patient. As long as the client is capable of making decisions, their consent is required for any procedure.

C: Although religious beliefs are respected, they do not serve as the primary deciding factor if the client is competent. The client's understanding and decision-making capacity are the key determinants in whether to proceed with the surgery.

D: The ethics committee can provide guidance on complex cases, but it cannot make decisions for a competent patient. The committee's role is advisory, and the final decision rests with the patient.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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