A charge nurse is teaching a newly licensed nurse about client confidentiality. When evaluating the newly licensed nurse's understanding of the teaching, which of the following responses should the charge nurse expect?

Rationale:

A. This option is incorrect as the first step because discussing the situation with the facility administrator may be necessary eventually, but initial action should involve objective documentation of observed behaviors rather than immediate reporting or action.

B. This option is correct because the nurse manager should first document thoroughly any unusual or concerning behaviors, incidents, or patterns. Objective documentation provides a factual basis for addressing the suspected substance use disorder and ensures the nurse manager can follow facility policies and legal requirements accurately.

C. This option is incorrect because imposing a suspension without investigation or objective evidence is premature, may violate facility policy, and could have legal consequences. Correct procedure requires documentation and adherence to established protocols for suspected impairment.

D. This option is incorrect because counseling the nurse before gathering documented evidence may not be appropriate. The nurse manager must follow facility policy, which typically starts with documentation and reporting to ensure safety and legal compliance, rather than immediately providing informal counseling.

Rationale:

A. This option is correct because the nurse’s first and highest priority is to ensure the client’s safety and assess for actual or potential injury. When a client reports a fall and pain, the nurse must immediately perform a focused assessment, checking for pain, swelling, deformity, range of motion, bleeding, or signs of head or spinal injury. This assessment guides all further actions and helps prevent worsening of a possible injury.

B. This option is incorrect because notifying the risk management department is an administrative and follow-up responsibility. While it is important for documentation and quality improvement, it should only be done after the client has been assessed, stabilized, and appropriate care has been initiated.

C. This option is incorrect because moving the client back to bed without first assessing for injuries could exacerbate a fracture, dislocation, or spinal injury. The nurse must determine whether it is safe to move the client and whether additional help or equipment is required before repositioning.

D. This option is incorrect because addressing the environmental hazard, such as drying the floor and posting warning signs, helps prevent future incidents but does not address the immediate needs of the injured client. Client assessment and safety take priority over environmental and preventive measures.