A nurse overhears two assistive personnel (AP) in the cafeteria discussing a client's care during lunch. Which of the following actions should the nurse take?
Ask the APs to discontinue the conversation.
Inform the client what has occurred.
Notify the client's provider.
Schedule a disciplinary conference for the APS.
The Correct Answer is A
Ask the APs to discontinue the conversation:
This is the most appropriate immediate action. Discussing a client's care in a public area violates the principle of patient confidentiality. The nurse should intervene promptly and ask the assistive personnel to stop the conversation.
Inform the client what has occurred:
While transparency with the client is important, it may not be the first action to take in this situation. The priority is to address the breach of confidentiality by stopping the conversation.
Notify the client's provider:
Notifying the client's provider is not the initial action to take in this situation. First, the nurse should address the immediate issue by stopping the inappropriate conversation. The provider may be informed later, if necessary.
Schedule a disciplinary conference for the APs:
Scheduling a disciplinary conference is a step that may be taken after addressing the immediate issue. The priority is to stop the inappropriate conversation and address confidentiality concerns before considering disciplinary actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use of the Braden scale for clients who are immobile.
The Braden Scale is a widely used tool for assessing the risk of pressure ulcer development. It includes various factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. For clients who are immobile, the Braden Scale helps identify their risk for skin breakdown and guides the implementation of preventive measures.
B. Daily weighing of clients who have heart failure:
Daily weighing of clients with heart failure is important for monitoring fluid status, but it is not specifically focused on decreasing the risk of skin breakdown. Skin breakdown is more closely related to factors such as immobility, pressure, and friction.
C. Documentation of PAINAD scale for clients who have dementia:
The PAINAD scale is used to assess pain in clients with advanced dementia. While managing pain is important for overall well-being, it is not a direct measure for decreasing the risk of skin breakdown. Skin breakdown prevention is more related to factors like pressure relief and moisture management.
D. Implementation of incentive spirometry for clients who are postoperative:
Incentive spirometry is primarily aimed at promoting lung expansion and preventing respiratory complications after surgery. While postoperative care is essential, it does not directly address the risk of skin breakdown. Skin breakdown prevention involves interventions related to pressure relief, repositioning, and skin care.
Correct Answer is ["125"]
Explanation
To calculate the IV pump rate (mL/hr), you can use the following formula:
Rate (mL/hr) = Total Volume (mL)/Total Time (hr)
In this case:
Rate=500 mL/4 hr
Rate=125mL/hr
Therefore, the nurse should set the IV pump to deliver 125 mL/hr for the lactated Ringer's IV infusion over 4 hours, rounded to the nearest whole number.
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