A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?
Report the observation to the nurse caring for that client.
Inform the nursing supervisor.
Approach the man and ask why he is making copies.
Notify hospital security.
The Correct Answer is C
Rationale:
A. Reporting the observation to the nurse caring for that client is important but not the immediate priority.
B. Informing the nursing supervisor is necessary but should be done after assessing the situation directly.
C. Approaching the man and asking why he is making copies is the most immediate and direct action. It allows the nurse to assess the situation and determine if the man has legitimate access to the client's medical record or if further action is needed.
D. Notifying hospital security may be necessary if the man’s actions are unauthorized, but the first step is to gather more information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Set a target date is crucial during the moving stage to create a timeline for implementation and facilitate progress towards the change.
B. Use tactics to alert staff nurses that a change is needed is part of the earlier stage of planning and communicating the need for change, not specifically the moving stage.
C. Evaluate the effectiveness of the change occurs after the change has been implemented, not during the moving stage.
D. Assess the problem is part of the initial stage of change, not the moving stage.
Correct Answer is ["A","B","C","D"]
Explanation
The nurse's documentation of the client being "inappropriate" is vague and unprofessional. Additionally, using the term "huge fall risk" without a specific assessment or plan to mitigate the risk (e.g., implementing fall precautions) is not adequate documentation. Further, the nurse’s reliance on physical or chemical restraints without exploring alternative interventions suggests a need for education on restraint use and patient safety practices.
The nurse's notes reflect a subjective description of the client's behavior as 'inappropriate' and 'complaining or arguing,' which is not objective or professional. It is important for nursing documentation to remain objective and to describe observed behaviors rather than labeling them. The statement that the client is "medically stable" should be supported by objective data rather than subjective observation, and it is important to note that mental health stability is also a crucial aspect of overall health.
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