A nurse stops at a motor vehicle collision to provide help for a victim who is trapped in an overturned running vehicle. The nurse turns off the engine key, and asks the client to wiggle the fingers because the client's head is impinged on the roof and the neck is bent to the left shoulder. After Emergency Medical Services (EMS) arrive, the nurse reports that the victim is conscious, but is not able to talk, and then the nurse leaves the scene. Which legal action can be taken in this situation?

A. Clamping the urinary catheter prior to the collection:

This step involves temporarily stopping the flow of urine through the catheter. Whether gloves are needed for this step depends on the specific protocol and the potential risk of exposure to bodily fluids. If there's a possibility of urine leakage or splashing during the clamping process, gloves may be necessary to protect against contact with the urine.

B. Recording the output on the flowsheet in the client's room:

This step involves documenting the urine output on a flowsheet or chart. It typically does not require direct contact with bodily fluids, as the nurse is handling paperwork rather than the urine itself. Therefore, gloves are usually not necessary for this task.

C. Transporting the urine specimen to the laboratory:

Once the urine specimen has been collected and properly sealed in a biohazard bag, the nurse transports it to the laboratory for analysis. As long as the specimen is securely packaged, there is no need for gloves during transportation unless there is a risk of spillage or leakage. However, if there is a possibility of contact with bodily fluids due to leakage, gloves should be worn to protect against exposure.

D. Using the syringe to remove the specimen from the catheter:

This step involves using a sterile syringe to withdraw the urine from the catheter for collection. Since it involves direct contact with bodily fluids (i.e., urine), gloves are necessary to protect against potential exposure to pathogens. Wearing gloves during this step helps maintain proper infection control practices and minimizes the risk of contamination.

A. Enter the occurrence after the 1400 notes and identify as "late entry":

While entering the occurrence after the 1400 notes is an option, labeling it as a "late entry" may not provide sufficient clarity regarding the timing of the documentation. Using a "late entry" label could potentially lead to confusion or misinterpretation.

B. Request removal initiated by the Health Information Manager:

Requesting removal of the 1400 notes by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation.

C. Create an electronic correction after 1400 notes are officially unlocked:

Making an electronic correction implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.

D. Make an electronic addendum following the 1400 documentation:

An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It's important to ensure that the addendum clearly identifies the timing of the documentation to maintain accuracy and transparency in the medical record.