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 D
Explanation
a. A client who reports night sweats and fever for the last week:
Night sweats and fever can be indicative of various underlying conditions, including infections. While these symptoms may require medical attention, they do not necessarily indicate an immediately life-threatening condition compared to other options.
b. A client who has compound fractures of the tibia and humerus:
Compound fractures involve broken bones that penetrate through the skin, leading to a risk of severe bleeding, infection, and other complications. This client's injuries are significant and require immediate attention to prevent further complications and provide pain management and stabilization.
c. A client who reports severe vomiting and diarrhea:
Severe vomiting and diarrhea can lead to dehydration, electrolyte imbalances, and other complications, especially if prolonged or accompanied by other symptoms such as fever. While this client requires prompt assessment and treatment, the urgency may not be as high as for other conditions.
d. A client who has soot markings around each naris following a house fire:
Soot markings around the nares (nostrils) suggest inhalation injury, which can lead to airway compromise, respiratory distress, and other serious complications. This client requires immediate assessment and intervention to ensure airway patency, oxygenation, and respiratory support.
Correct Answer is C
Explanation
a. Complete an incident report about the breach of client confidentiality:
While documenting the incident is important, completing an incident report alone may not address the immediate need to stop the breach of confidentiality.
b. Reassign the AP to other clients on the unit:
Reassignment may be considered after addressing the immediate issue, but it doesn't directly address the inappropriate conversation.
c. Instruct the AP to discontinue the conversation:
This is the correct immediate action. The nurse should intervene and instruct the assistive personnel to stop discussing the client's care in a non-secure location like the cafeteria.
d. Notify the client’s provider about the incident:
While notifying the client's provider may be necessary in certain situations, the immediate concern is to stop the breach of confidentiality and address the inappropriate conversation.
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