A nurse has just completed assessment charging on the electronic record for an assigned client. An assistive personnel who just measured the client’s vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take?
Recommend the AP come back later when the record is available
Log out so the AP can log in to document the vital signs
Offer to chart the vital signs for the AP
Allow the AP to document the vital signs prior to logging out
The Correct Answer is B
a. Recommend the AP come back later when the record is available:
This option delays the documentation process unnecessarily and may inconvenience the AP.
It doesn't address the issue of maintaining patient confidentiality and accurate documentation.
b. Log out so the AP can log in to document the vital signs:
This is the correct choice as it ensures that each individual's documentation is attributed to the correct user.
It maintains patient confidentiality and adheres to HIPAA regulations.
It allows the AP to complete their task efficiently while preserving the integrity of the electronic record.
c. Offer to chart the vital signs for the AP:
This option involves the nurse taking over the responsibility of documenting the vital signs for the AP, which could lead to confusion and potential errors.
It's not the most appropriate solution as it may not be feasible for the nurse to document the vital signs accurately without directly measuring them.
d. Allow the AP to document the vital signs prior to logging out:
Allowing the AP to document vital signs under the nurse's login compromises the integrity of the electronic record and violates HIPAA regulations.
It's not an acceptable practice as it can lead to inaccuracies in the documentation and compromises patient confidentiality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Alert the infection control department:
While the infection control department plays a role in ensuring proper infection prevention practices, directly alerting them may not be the most immediate action to take. The charge nurse should first address the issue internally before escalating it to other departments.
b. Discuss the issue with the AP:
This is the most appropriate initial action to take. Speaking directly with the assistive personnel allows the charge nurse to clarify the correct protocol, provide education or retraining if necessary, and address any misunderstandings or lapses in adherence to facility policies.
c. Reinforce facility protocols at the next staff meeting:
While reinforcing facility protocols is important, waiting until the next staff meeting may not address the immediate concern of the observed failure to follow protocol. Direct communication with the individual involved is more effective for addressing the specific incident in a timely manner.
d. Notify the unit manager about the incident:
Notifying the unit manager about the incident may be necessary if the issue persists or if further action is required beyond the initial discussion with the assistive personnel. However, it may not be the first step to take when addressing an isolated incident.
Correct Answer is ["C"]
Explanation
a. Store opened bottles of normal saline in a refrigerator for up to 48 hours:
Incorrect. Once opened, bottles of normal saline should generally be used within a short time frame (typically 24 hours) and should not be stored for extended periods to prevent contamination. This practice could lead to infection risks and is not recommended as a cost-containment measure.
b. Wait to dispose of sharps containers until they are completely full:
Incorrect. Overfilling sharps containers increases the risk of needle-stick injuries and potential exposure to bloodborne pathogens. Sharps containers should be disposed of when they are about three-quarters full to maintain safety.
c. Use clean gloves rather than sterile gloves for colostomy care:
Correct. For colostomy care, clean gloves are generally sufficient as it is a clean procedure, not a sterile one. Using clean gloves instead of sterile gloves reduces costs without compromising patient safety.
d. Return unused supplies from the bedside to the unit’s supply stock:
Incorrect. Returning unused supplies to the general supply stock can pose a risk of cross-contamination and infection. Once supplies have been brought to a patient's bedside, they are considered contaminated and should not be returned to the supply area.
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