A nurse is providing postoperative care for a patient who has a closed-wound drainage system. Which of the following actions should the nurse perform?

Choice A rationale:

It is crucial for the nurse to prioritize patient safety and adhere to professional guidelines when encountering a potential diversion of controlled substances. Informing the charge nurse is the most appropriate initial action for several reasons:

Chain of Command: The charge nurse holds a supervisory position and is responsible for addressing issues within the unit, including concerns about medication diversion. Reporting suspicions to the charge nurse ensures adherence to the established chain of command and facilitates a prompt, organized response.

Confidentiality and Objectivity: The charge nurse is trained to handle sensitive situations discreetly and objectively. They can initiate a thorough investigation while maintaining confidentiality and protecting the rights of all involved parties.

Access to Resources: The charge nurse has access to resources and authority to take immediate action, such as securing medications, initiating patient assessments, and notifying appropriate personnel within the healthcare facility.

Collaboration and Support: The charge nurse can provide guidance and support to the reporting nurse, ensuring their concerns are addressed appropriately and that they feel safe in coming forward with their suspicions.

Rationale for other choices:

B. Reporting the incident directly to the hospital’s security department might be premature without first informing the charge nurse. The charge nurse can assess the situation, gather more information, and determine the most appropriate course of action, which may or may not involve security at this initial stage.

C. Requesting assistive personnel (AP) to monitor the other nurse’s actions is inappropriate. It places a burden on APs who are not trained or authorized to investigate such matters. It could also compromise the integrity of the investigation and potentially jeopardize patient safety.

D. Confronting the other nurse directly is not recommended. It could escalate the situation, create a hostile work environment, and potentially compromise the investigation. It is essential to follow established protocols and involve appropriate personnel to ensure a fair and thorough investigation.

The correct answer is choiceD.

Choice A rationale:

Assisting the client back into bed is not the initial action.Moving the client without assessing their condition could potentially cause harm.

Choice B rationale:

Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.

Choice C rationale:

Informing the client’s family member is not the immediate priority.The nurse should first ensure the client’s safety and assess their condition.

Choice D rationale:

Obtaining the client’s vital signs is the initial action.This helps assess the client’s current condition and determine if there are any immediate medical needs.