A nurse posts a photo of a patient without the patient’s consent. Which principle has the nurse violated?

Choice A rationale
Correcting the physician’s orders to match the chart is not within the nurse’s scope of practice. Nurses should not alter physician orders.
Choice B rationale
Ignoring the discrepancy is not appropriate. Nurses have a responsibility to ensure patient safety and accurate documentation.
Choice C rationale
Documenting the discrepancy but taking no further action does not address the potential risk to patient safety. Further action is necessary.
Choice D rationale
Documenting the discrepancy and notifying the physician is the correct course of action. This ensures that the physician is aware of the issue and can make any necessary corrections.

Choice A rationale
The statement “The vital signs are stable” is incorrect for the fifth step of the SBAR communication tool. The fifth step in SBAR is the Recommendation step, where the nurse provides a recommendation or request for what action should be taken next. Stating that the vital signs are stable does not provide a clear recommendation or action plan for the provider to follow.
Choice B rationale
The statement “The client has a history of high blood pressure” is incorrect for the fifth step of the SBAR communication tool. This information belongs in the Background step, where the nurse provides relevant clinical background information about the patient’s condition. The Recommendation step should focus on what action the nurse recommends based on the assessment.
Choice C rationale
The statement “The client should be seen by a neurologist” is correct for the fifth step of the SBAR communication tool. In the Recommendation step, the nurse provides a clear and specific recommendation for what action should be taken next. Recommending that the client be seen by a neurologist is an appropriate and actionable recommendation based on the nurse’s assessment.
Choice D rationale
The statement “The client is experiencing severe headaches” is incorrect for the fifth step of the SBAR communication tool. This information belongs in the Assessment step, where the nurse provides an analysis of the patient’s current condition. The Recommendation step should focus on what action the nurse recommends based on the assessment.