A nurse is assisting with the care of a client.

Exhibits

The nurse is reinforcing teaching for the client and their family about potential adverse effects of the client's prescribed medications.

For each potential adverse effect, click to specify if the effect is. consistent with agranulocytosis, neuroleptic malignant syndrome, or. serotonin syndrome.

Each finding may support more than 1 disease process.

The correct answer is Choice D.

Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.

Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.

Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.

Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.

The correct answer is: B. Secure the tubing with adhesive tape to the lower abdomen.

Choice A rationale: Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine reflux, which can lead to urinary tract infections (UTIs).

Choice B rationale: Securing the tubing with adhesive tape to the lower abdomen is correct as it helps to prevent accidental pulling or tugging on the catheter, maintaining its position and reducing the risk of dislodgement.

Choice C rationale: Collecting a sterile specimen from the urinary drainage bag is incorrect. Specimens should be collected from the sampling port, not directly from the drainage bag, to ensure sterility.

Choice D rationale: Coiling the tubing on the bed above the collection bag is incorrect as it can cause urine to flow back into the bladder, increasing the risk of infection.