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: 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.

A. A client who has active bleeding from a puncture wound to the groin area B. A client who has a raised red skin rash on his arms, neck, and face C. A client who reports shortness of breath and left shoulder and neck pain D. A client who reports right-sided flank pain

Correct Answer is C

Explanation

A. A client with active bleeding from a puncture wound to the groin area requires immediate attention; however, the priority is determined by assessing the severity and potential complications associated with each condition.

B. A raised red skin rash could indicate an allergic reaction or infection, but it is not life-threatening compared to respiratory distress.

C. A client who reports shortness of breath and left shoulder and neck pain is the highest priority because these symptoms can indicate a serious condition, such as a myocardial infarction or pulmonary embolism. Both conditions require urgent assessment and intervention to prevent deterioration.

D. Right-sided flank pain can indicate kidney stones or other issues but is less critical than the risk of respiratory compromise present in option C.

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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

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