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
Choice A rationale:
Sarcoptes scabiei is the causative agent of scabies, a contagious skin infestation. While scabies is a communicable disease, it is typically not a reportable disease to the state health department. Scabies is usually treated at the individual or community level, and reporting to the state health department is not required.
Choice B rationale:
Neisseria gonorrhoeae is the bacterium responsible for gonorrhea, a sexually transmitted infection. Gonorrhea is a notifiable disease, and healthcare providers are required to report cases of gonorrhea to the state health department. This is because gonorrhea is a significant public health concern due to its potential complications and the need for contact tracing and prevention.
Choice C rationale:
Human papillomavirus (HPV) is a very common sexually transmitted infection, but it is typically not a reportable disease to the state health department. HPV can lead to various health issues, including genital warts and certain types of cancer. However, reporting HPV cases is not a standard practice because it is highly prevalent and usually managed at the individual level through screening and vaccination programs.
Choice D rationale:
Impetigo contagiosa is a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes. While it is contagious, impetigo is not typically a reportable disease to the state health department. Like scabies, impetigo is usually managed at the individual or community level, and reporting is not a standard requirement.
Correct Answer is A
Explanation
Choice A rationale:
Informed consent is required for invasive procedures that carry significant risks or potential complications. Placement of a central venous catheter is an invasive procedure that involves inserting a catheter into a large vein, often in the neck, chest, or groin. It carries potential risks such as infection, bleeding, and injury to nearby structures. Therefore, informed consent is necessary before performing this procedure.
Choice B rationale:
Insertion of a nasogastric tube is an invasive procedure, but it is generally considered a routine and less risky procedure compared to others. Informed consent is typically not required for nasogastric tube insertion unless there are specific institutional policies or the client lacks decision-making capacity.
Choice C rationale:
Irrigation of a wound with antibiotic solution is a standard nursing procedure, and informed consent is not typically required for wound care unless there are specific circumstances that make it necessary, such as unusual risks or patient-specific considerations.
Choice D rationale:
Administration of an iron injection using Z-track technique is also an invasive procedure, but it is a common and well-established technique for administering intramuscular injections. Informed consent is not routinely required for this procedure unless there are specific institutional policies or the client's condition warrants it.
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