A nurse has just completed assessment charting on the electronic record for an assigned client. An assistive personnel (AP) 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?

Allow the AP to document the vital signs prior to logging out.

Log out so the AP can log in to document the vital signs.

Offer to chart the vital signs for the AP.

Recommend the AP come back later when the record is available.

Answer and Explanation

The Correct Answer is B

Choice A reason: Allowing the AP to document the vital signs prior to logging out is not a correct action, as it violates the principles of confidentiality and accountability. The nurse should not share their login credentials or allow anyone else to use their electronic record.

Choice B reason: Logging out so the AP can log in to document the vital signs is the correct action, as it ensures that the documentation is accurate, timely, and secure. The nurse should log out of the electronic record after completing their charting and allow the AP to log in using their own credentials.

Choice C reason: Offering to chart the vital signs for the AP is not a correct action, as it delays the documentation and increases the risk of errors. The nurse should not chart the vital signs for the AP, as they are not the ones who obtained them.

Choice D reason: Recommending the AP come back later when the record is available is not a correct action, as it also delays the documentation and reduces the availability of the electronic record. The nurse should not make the AP wait for the record, as it may affect the continuity of care.

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Correct Answer is B

Explanation

Choice A reason: Closing the fire doors and the doors to the clients' rooms is an action that the nurse should take after activating the fire alarm, as it helps to contain the fire and prevent smoke inhalation.

Choice B reason: Activating the fire alarm is the first action that the nurse should take after removing the client from the room, as it alerts the fire department and the rest of the staff and clients about the fire.

Choice C reason: Extinguishing the fire is an action that the nurse should take only if the fire is small and confined, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should use the appropriate fire extinguisher and follow the PASS technique (pull, aim, squeeze, sweep).

Choice D reason: Removing all clients from the unit is an action that the nurse should take only if the fire is large and spreading, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should follow the RACE protocol (rescue, alarm, confine, extinguish/evacuate) and the facility's emergency plan.

A. "Please ask your relative about this, because I cannot share information about her." B. "I'm not taking care of your relative today, so I don't have the latest information." C. "I will have your relative's nurse come and talk with you about her care." D. "Let me check your relative's medical record to see how she's doing."

Correct Answer is C

Explanation

Choice A reason: This response is inappropriate because it violates the client's right to privacy and confidentiality. The nurse should not disclose any information about the client to anyone without the client's consent, unless it is required by law or for the client's safety.

Choice B reason: This response is inappropriate because it shows a lack of accountability and professionalism. The nurse should not dismiss the visitor's concern or pass the responsibility to another nurse. The nurse should either provide the information if they have it or direct the visitor to the appropriate source.

Choice C reason: This response is appropriate because it respects the client's privacy and confidentiality, while also addressing the visitor's concern. The nurse should inform the visitor that they will contact the nurse who is taking care of the client and ask them to come and talk with the visitor.

Choice D reason: This response is inappropriate because it violates the client's privacy and confidentiality. The nurse should not access the client's medical record without a valid reason or the client's consent. The nurse should only check the medical record if they are involved in the client's care or have a need to know the information.

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A nurse has just completed assessment charting on the electronic record for an assigned client. An assistive personnel (AP) 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?

Correct Answer is B

Explanation

A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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