A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

Choice A Reason:
Escorting the nurses to the nurses' lounge to continue the discussion is incorrect. While removing the nurses from a public area to discuss the matter further might seem like a good idea, it does not address the underlying issue of unprofessional behavior and inappropriate discussion about patient care. The charge nurse should intervene to address the situation more formally.
Choice B Reason:
Contacting the house supervisor to mediate the conflict is correct. Contacting the house supervisor ensures that the issue is escalated appropriately and that a neutral party with authority can intervene to mediate the conflict. The house supervisor can help address the nurses' concerns while emphasizing the importance of professionalism and patient-centered care.
Choice C Reason:
Recommending that both nurses be terminated is incorrect. Termination should only be considered after a thorough investigation and due process. Jumping to termination as the first course of action is inappropriate and may not be warranted in this situation, especially without understanding the full context and reasons behind the nurses' behavior.
Choice D Reason:
Making arrangements to take over the client's care is incorrect. While ensuring continuity of care for the client is important, taking over the client's care without addressing the underlying issue of unprofessional behavior and inappropriate discussion about patient care does not address the root cause of the problem. It's important to address the behavior of the nurses through appropriate channels and ensure that they understand the importance of professionalism and patient confidentiality.

Choice A Reason:
Telling the client that their blood alcohol level will be checked is incorrect. Threatening the client with other forms of testing may not be ethically or legally appropriate, especially if the client has refused the initial request. It's important to respect the client's autonomy and right to refuse testing.
Choice B Reason:
Informing the client that a catheter will be inserted is incorrect. Inserting a catheter against the client's will is invasive and would constitute a violation of the client's autonomy and bodily integrity. It is not an appropriate action.
Choice C Reason:
Documenting the client's refusal in their chart is correct. Documenting the client's refusal is essential for accurate record-keeping and ensures that the healthcare team is aware of the client's decision. It also helps protect the nurse and the healthcare facility in case of any legal or ethical challenges related to the client's refusal.
Choice D Reason:
Assessing the client for urinary retention is incorrect. While urinary retention may be a concern in some cases, it is not the immediate action to take when a client refuses to provide a urine sample. The priority is to respect the client's autonomy and document their refusal appropriately. If there are clinical indications or concerns about urinary retention, they can be assessed separately and addressed accordingly.