A nurse is reinforcing teaching with a newly licensed assistive personnel (AP) who has violated a client's confidentiality. Which of the following actions should the nurse take? (Select all that apply.)
Decline documenting the first counseling session.
Communicate expected behavior to the AP.
Explain to the AP the consequences of the behavior.
Allow the AP time to respond to the counseling information.
Conduct the counseling session with another AP present.
Correct Answer : B,C,D
A. Decline documenting the first counseling session: Documentation is necessary to maintain accurate records of counseling sessions.
B. Communicate expected behavior to the AP: Reinforcing the expectations helps clarify appropriate behavior.
C. Explain to the AP the consequences of the behavior: Understanding potential consequences encourages adherence to confidentiality standards.
D. Allow the AP time to respond to the counseling information: Allowing the AP to respond fosters a two-way communication approach and encourages accountability.
E. Conduct the counseling session with another AP present: Counseling sessions should remain private to maintain confidentiality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A newborn has respiratory distress and requires oxygen: This is a clinical event requiring immediate intervention but not necessarily an error or unexpected event warranting an incident report.
B. A newborn has an Apgar score of 7 at 5 minutes after birth: An Apgar score of 7 is within a normal range and does not constitute an unusual or reportable incident.
C. A newborn receives erythromycin ophthalmic ointment 4 hours after birth: Erythromycin should be administered within 1 to 2 hours after birth to prevent neonatal eye infections. Delayed administration requires incident reporting.
D. A newborn receives a heel stick on the outer aspect of the heel: This is standard practice to prevent nerve and tissue damage during blood sampling and does not require an incident report.
Correct Answer is C
Explanation
A. Obtain informed consent from the client for the blood transfusion: Verifying that informed consent is obtained is essential, but obtaining consent is the provider's responsibility. The nurse's role is to ensure the consent has been signed and documented.
B. Delegate the client's care to an RN: If the nurse receiving the shift report is already an RN, delegating the care to another RN is unnecessary unless there are specific time constraints or workload considerations.
C. Access the nursing information system for guidelines about blood transfusions: This is an appropriate action to ensure that institutional policies and guidelines are followed regarding blood administration, which may include steps for patient identification, infusion rates, and monitoring for reactions.
D. Inform the charge nurse of the need to reassign the client's care: This is typically not necessary unless the assigned nurse lacks the competency to administer blood products or has competing responsibilities that prevent safe monitoring of the transfusion.
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