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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because a social worker can help the parent with financial assistance, insurance coverage, or other resources to obtain the nebulizer and the medication for the child. A social worker can also provide emotional support and education to the parent and the child about asthma management.
Choice B reason: This is not the correct choice because a pharmacist can only provide information about the medication, such as the dosage, side effects, and interactions. A pharmacist cannot help the parent with the cost of the nebulizer or the medication.
Choice C reason: This is not the correct choice because child protective services is not a referral that the nurse should recommend in this situation. The parent is not neglecting or abusing the child, but rather expressing a concern about the affordability of the nebulizer. Reporting the parent to child protective services could cause more harm than good to the parent-child relationship and the child's well-being.
Choice D reason: This is not the correct choice because a respiratory therapist can only provide technical assistance and education on how to use the nebulizer and the medication. A respiratory therapist cannot help the parent with the cost of the nebulizer or the medication.
Correct Answer is D
Explanation
Choice A reason: The most recent blood glucose reading is not the most important information for the nurse to report at shift change. IV corticosteroids can cause hyperglycemia, which requires monitoring and treatment, but it is not as critical as the client's level of consciousness.
Choice B reason: The laboratory tests scheduled for next shift are not the most important information for the nurse to report at shift change. The nurse should inform the oncoming nurse about the tests, but they are not as urgent as the client's neurological status.
Choice C reason: The reddened area on the coccyx is not the most important information for the nurse to report at shift change. The nurse should document and report any signs of skin breakdown, but they are not as life-threatening as the client's increased intracranial pressure.
Choice D reason: The Glasgow Coma Scale score is the most important information for the nurse to report at shift change. The Glasgow Coma Scale is a tool that measures the client's level of consciousness based on eye opening, verbal response, and motor response. A decrease in the score indicates a deterioration in the client's neurological condition, which requires immediate intervention.
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