A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted.
Which of the following actions should the nurse take?

Document the event in the client's progress notes.

Submit an incident report to the risk manager.

Inform the client of the APs' actions.

Tell the APs to stop the conversation.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.

Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.

Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.

Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.

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Correct Answer is D

Explanation

Choice A rationale:

Allowing the patient to lift the CPM machine onto the bed is not a safe practice. Arthroscopic surgery may result in limited mobility and discomfort for the patient. Lifting heavy equipment could potentially strain the surgical site or lead to injury.

Choice B rationale:

Telling the patient that CPM will not hurt at all is not accurate. While CPM is a passive motion technique aimed at preventing joint stiffness, some discomfort or mild pain may be experienced, especially during the initial sessions. Managing the patient's pain is essential to ensure compliance with the CPM exercises.

Choice C rationale:

Suggesting that the patient does not need to do CPM exercises is incorrect. CPM exercises are often prescribed after joint surgery to prevent joint stiffness, improve circulation, and aid in recovery. Discouraging the patient from participating in these exercises would be detrimental to their postoperative outcome.

Choice D rationale:

Administering an opioid analgesic to the client 30 minutes before initiating CPM exercises is the correct choice. CPM exercises can be uncomfortable for some patients, especially in the initial stages, and providing adequate pain relief before starting the exercises promotes patient comfort and compliance. It helps ensure that the patient can perform the exercises effectively without undue pain, reducing the risk of complications and promoting a successful recovery.

A. Vitamin D. B. Protein. C. Calcium. D. Fats.

Correct Answer is B

Explanation

Choice A rationale:

While vitamin D is essential for bone health and wound healing, it is not the primary nutrient to focus on in this case. Protein plays a crucial role in wound healing because it is necessary for tissue repair and the production of collagen, which is essential for wound closure.

Choice B rationale:

Increasing protein intake is the correct choice. Proteins are the building blocks of tissue repair and wound healing. Adequate protein intake is essential for promoting the healing of open wounds.

Choice C rationale:

Calcium is important for bone health but is not the primary nutrient to address in this situation. Calcium is not directly involved in wound healing processes.

Choice D rationale:

Fats are necessary for overall health, but they do not have a direct role in wound healing. Protein intake is more critical in this context to promote tissue repair and healing.

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A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

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A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted.
Which of the following actions should the nurse take?