A nurse is observing an assistive personnel (AP). For which of the following actions by the AP should the nurse intervene?
Logs off the computer after entering a client's intake and output totals.
Tears a document with client information in half before disposing of it in a waste basket.
Denies a request by another AP to use her password to enter client's vital signs.
Removes a clipboard with client information from the room during visiting hours.
The Correct Answer is B
The nurse should intervene when the AP tears a document with client information in half before disposing of it in a waste basket. This is because client information is confidential and should be disposed of properly to protect the client's privacy. Tearing a document in half is not sufficient to ensure that the information is protected.
Option A is incorrect because logging off the computer after entering a client's intake and output totals is an appropriate action.
Option C is incorrect because denying a request by another AP to use her password to enter the client's vital signs is an appropriate action to protect the client's information.
Option D is incorrect because removing a clipboard with client information from the room during visiting hours may be necessary to protect the client's privacy.
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Related Questions
Correct Answer is C
Explanation
An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone— patient, staff member, or visitor—is injured or involved in a situation with the potential for injury, an incident report is required ⁴. In this case, the client's missing dentures would be considered a complaint and would require the nurse to complete an incident report.
The other options do not require an incident report. Disagreeing with the nurse manager about inadequate staffing [a], a staff member not arriving at the facility to work an assigned shift [b], and discovering that the client does not have advanced directives [d] are not situations that would require an incident report according to the information provided in my sources.
Correct Answer is A
Explanation
If a nurse is assisting with the care of a group of pediatric clients, the first action the nurse should take is to deliver a breakfast tray to a child who has been administered regular insulin. This is because regular insulin is a fast-acting insulin that begins to lower blood sugar levels within 15 minutes of administration. It is important for the child to eat shortly after receiving regular insulin to prevent hypoglycemia.
Option B is incorrect because completing pin site care for a child who is in skeletal traction is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option C is incorrect because providing clear liquids to a child who is 4 hr postoperative following a laparoscopic appendectomy is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option D is incorrect because administering acetaminophen to a child who has a temperature of 101.2°F (38.4°C) is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
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