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:
Uncapped sharps being put in a puncture-resistant container (choice A) is a safe and appropriate practice for the disposal of sharp objects, such as needles. This choice demonstrates adherence to infection control principles and minimizes the risk of accidental needlestick injuries.
Choice B rationale:
Soiled linens being placed on the floor (choice B) is not a safe or acceptable practice. Placing soiled linens on the floor can lead to contamination of the environment and pose a risk of spreading infection. Proper linen disposal protocols should be followed, which may include using designated linen hampers or containers.
Choice C rationale:
Waste containers being lined with single bags (choice C) is a standard practice for waste disposal. Using single bags makes it easier to handle and dispose of waste materials safely. It is a recommended infection control measure.
Choice D rationale:
Dampened cloths being used for dusting the area (choice D) is generally a safe practice for cleaning and dusting surfaces. Dampened cloths can help prevent the spread of dust and allergens. However, it's essential to ensure that the cloths are cleaned and disinfected regularly to prevent bacterial growth.
Correct Answer is A
Explanation
Choice A rationale:
Monitoring for muscle paralysis is crucial in botulism poisoning because it is a characteristic symptom of the condition. Botulinum toxin causes muscle weakness and paralysis, which can lead to respiratory distress. Monitoring for these symptoms allows for timely intervention.
Choice B rationale:
Placing the client in contact isolation is not a priority in botulism poisoning. Botulism is not typically transmitted from person to person, so isolation is not necessary. The focus should be on monitoring and supportive care.
Choice C rationale:
Checking for increased salivation is important because excessive salivation is a symptom of botulism poisoning. However, monitoring for muscle paralysis is more critical as it can lead to respiratory compromise.
Choice D rationale:
Administering clindamycin hydrochloride is not a standard treatment for botulism poisoning. The primary treatment involves supportive care and, in some cases, the administration of antitoxin if available.
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