A nurse receives notification of a fire on the unit. Which of the following actions should the nurse take first?

Answer is: d. "Clients are the experts on their own pain."

Explanation: The charge nurse's response acknowledges the client's self-report of pain, which is considered the most reliable indicator of pain presence and intensity. This approach emphasizes the importance of individualized pain management and respects the client's autonomy.

Statement a. is wrong because the nurse is suggesting an intervention without assessing the client's pain or consulting the healthcare provider. Although nonpharmacological interventions may be appropriate, they should be discussed with the client and provider before making decisions.

Statement b. is wrong because withholding prescribed medication without a valid reason or consultation with the healthcare provider is inappropriate and could result in inadequate pain management.

Statement c. is wrong because contacting mental health services for a consultation based on the assumption that the client is seeking drugs may be premature and overlook the client's reported pain. A thorough assessment and discussion with the healthcare provider should precede any consultation.

Choice A rationale:

Giving change-of-shift report at the client's bedside is not appropriate due to privacy concerns. The client's room is not a private area for discussing their medical information, and other clients or visitors might overhear sensitive details. A more appropriate location, such as a designated nursing station, should be used for shift handoffs.

Choice B rationale:

Providing client information over the phone to callers identifying themselves as family is incorrect. Even if the caller identifies as family, the nurse cannot verify their identity over the phone. Sharing confidential client information without proper verification violates confidentiality policies and can compromise the client's privacy.

Choice C rationale:

Stating that the client cannot see their medical record because it is considered property of the facility is incorrect. Clients have the legal right to access their medical records under the Health Insurance Portability and Accountability Act (HIPAA). While the physical record might be owned by the facility, clients have the right to review their medical information.

Choice D rationale:

Access to client information is limited to direct care providers is the correct statement. Confidentiality requirements dictate that only authorized individuals involved in the client's care, treatment, or payment processes have access to their medical information. This helps protect the client's privacy and ensures that sensitive information is not disclosed to unauthorized parties.