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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Bradycardia is not typically associated with a perforated appendix. Instead, tachycardia (increased heart rate) may occur due to pain and infection-related systemic responses. Bradycardia could indicate other unrelated medical issues and should still be monitored.
Choice B rationale: Elevated temperature is a key sign of infection and inflammation, which are common with a perforated appendix. The release of bacteria into the abdominal cavity can cause peritonitis, leading to fever as part of the body's immune response.
Choice C rationale: Lethargy can be a nonspecific symptom and may occur in various conditions. While it can be associated with severe infection, it is not a definitive indicator of a perforated appendix. Monitoring for more specific signs, like fever and pain, is crucial.
Choice D rationale: Decreased abdominal girth is unlikely and not indicative of a perforated appendix. Instead, an increase in abdominal girth due to fluid accumulation (ascites) or air (from perforation) would be more concerning and should be reported promptly.
Correct Answer is A
Explanation
Choice A rationale:
"Determine the client's ability to use the call light." - This is the correct answer. Assessing the client's ability to use the call light is the first step in fall prevention. If the client can effectively use the call light, they can request assistance when needed, reducing the risk of falls. It's essential to assess their communication and mobility abilities.
Choice B rationale:
"Create a schedule with an assistive personnel to do hourly rounding for the client." - While hourly rounding is a valuable fall prevention strategy, assessing the client's ability to use the call light should be the initial step to ensure immediate access to help. Rounding can complement this measure.
Choice C rationale:
"Move the bedside table with the client's personal items close to the bed." - While ensuring the client's personal items are within reach is important for their comfort and convenience, it is not the first step in fall prevention. Assessing the client's ability to request assistance takes precedence.
Choice D rationale:
"Apply rubber-soled slippers before ambulation." - Providing appropriate footwear is important for fall prevention, but it is not the first precaution to implement. Assessing the client's ability to use the call light and communicate their needs comes before addressing ambulation.
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