While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?
Reinforce the potential consequences of not having this information on record to the nursing staff.
Remind nurses to obtain this information during the admission process.
Meet with nursing staff to review the policy regarding advance directives.
Ask nurses who are caring for clients without this information in the medical record to obtain it.
The Correct Answer is D
Choice A Reason:
Reinforcing the potential consequences of not having advance directives on record is important, but the immediate priority is to ensure that the missing documentation is obtained.
Choice B Reason:
Reminding nurses to obtain advance directive information during the admission process is a proactive approach to preventing future instances of missing documentation. However, the priority now is to address the current gap in documentation for clients already admitted.
Choice C Reason:
Meeting with nursing staff to review the policy regarding advance directives can provide clarification and reinforcement of expectations, but again, the immediate priority is to address the missing documentation for current clients.
Choice D Reason:
Asking nurses who are caring for clients without this information in the medical record to obtain it. The priority action for the nurse manager is to ensure that advance directives, which are critical documents outlining a patient's wishes regarding medical treatment, are obtained for clients who currently lack documentation. This ensures that patients' preferences and choices regarding their care are respected, especially in critical situations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
A toddler who cries whenever their parent enters the examination room is incorrect. Toddlers may exhibit separation anxiety or fear of medical procedures, which is a common behavior in this age group.
Choice B Reason:
An adolescent who was admitted and refuses to speak to their parents is incorrect. Adolescents may exhibit behaviors such as withdrawal or reluctance to communicate with parents due to developmental changes, stress, or other factors unrelated to maltreatment.
Choice C Reason:
A preschooler who was previously toilet trained and now requires diapers in the hospital is incorrect. Regression in toileting skills is common in preschoolers during times of stress or illness, such as hospitalization. It does not necessarily indicate maltreatment but may be a response to the unfamiliar environment or medical condition.
Choice D Reason:
A school-age child who has several abrasions on their lower legs is correct. Abrasions on a school-age child's lower legs could potentially indicate physical abuse or neglect, especially if they are unexplained or inconsistent with the child's reported activities. Reporting such findings for further investigation is essential to ensure the safety and well-being of the child.
Correct Answer is A
Explanation
Choice A Reason:
"I will have a client who is on airborne precautions wear a mask when out of her room." This statement demonstrates understanding of airborne precautions. Clients on airborne precautions, such as those with tuberculosis or measles, should wear a mask when they leave their room to prevent the spread of infectious droplets.
Choice B Reason:
"I will place a client who has compromised immunity in a negative-pressure airflow room." While placing a client with compromised immunity in a negative-pressure airflow room may be appropriate in some cases to reduce the risk of exposure to pathogens, it is not a standard precaution and is not applicable to all clients with compromised immunity.
Choice C Reason:
"I will instruct visitors to wear a mask when visiting a client who is on contact precautions." This statement indicates an understanding of contact precautions. Visitors should wear appropriate personal protective equipment, such as gloves and gowns, when visiting clients on contact precautions to prevent the transmission of infectious agents.
Choice D Reason:
"I will wear an N95 respirator mask when caring for a client who is on droplet precautions." This statement demonstrates understanding of droplet precautions. Healthcare providers should wear a surgical mask when caring for clients on droplet precautions, as it helps prevent the transmission of respiratory droplets generated by the client through coughing, sneezing, or talking. N95 respirator masks are typically reserved for airborne precautions.
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