A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take?

Complete an incident report.

Take the specimen to the laboratory.

Report the AP to the charge nurse.

Ask the AP about her concerns with the assignment.

Answer and Explanation

The Correct Answer is D

A.   Completing an incident report may be necessary if the refusal could potentially impact patient care or if there are policies or procedures in place that require documenting such incidents. It helps to document the details of the refusal and any subsequent actions taken.
B.   If the AP refuses to take the specimen, the nurse may need to take responsibility for ensuring the specimen is delivered to the laboratory promptly. This ensures that patient care activities are not delayed and that necessary diagnostic tests are performed in a timely manner.
C.   Reporting the refusal to the charge nurse or supervisor is appropriate, especially if there are concerns about the AP's behavior or if it is part of the facility's policy to escalate such incidents. The charge nurse can then address the situation and determine the appropriate course of action.

D.   Communicating with the AP to understand their concerns is essential. It allows the nurse to clarify any misunderstandings, address any issues or barriers the AP may have, and potentially resolve the situation collaboratively. It's important to listen to the AP's perspective and provide clarification or reassurance if needed.

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Correct Answer is D

Explanation

A. Metolazone is a thiazide-like diuretic that works primarily in the distal convoluted tubule of the nephron. It can lead to hyponatremia due to its mechanism of increasing sodium and water excretion. However, it is not typically associated with hyperkalemia.
B. Furosemide is a loop diuretic that acts on the ascending loop of Henle. It primarily causes loss of sodium, potassium, and chloride ions. While it can lead to hypokalemia (low potassium levels) due to increased potassium excretion, it does not typically cause hyperkalemia or hyponatremia.
C. Hydrochlorothiazide is a thiazide diuretic that acts on the distal convoluted tubule. It can cause hyponatremia due to increased sodium and water excretion. It may also lead to hypokalemia but is not typically associated with hyperkalemia.
D. Spironolactone is a potassium-sparing diuretic that works by antagonizing aldosterone receptors in the distal nephron, leading to retention of potassium and excretion of sodium. It can cause hyperkalemia due to its potassium-sparing effects. Additionally, it may also lead to hyponatremia, although less commonly than thiazide diuretics.

A. Assessment B. Planning C. Implementation D. Evaluation

Correct Answer is A

Explanation

A. Assessment is the first phase of the nursing process where the nurse collects data about the client's health status, including medical history, current symptoms, and potential allergies. During the assessment phase, the nurse should specifically ask the client about any known allergies to medications, foods, or other substances. This information is crucial for ensuring patient safety during diagnostic testing and any subsequent treatments.
B. The planning phase involves developing a care plan based on the assessment data gathered. While the nurse does consider potential allergies during this phase when planning interventions and care strategies, the primary focus is on creating a plan that addresses the client's specific needs and goals.
C. Implementation is the phase where the nurse carries out the interventions outlined in the care plan. If the client has allergies identified during the assessment phase, the nurse must ensure that these allergies are communicated to the healthcare team and that appropriate precautions are taken during diagnostic testing and any procedures or treatments.

D. Evaluation is the final phase of the nursing process where the nurse assesses the client's response to interventions and determines the effectiveness of the care plan. Although allergies are primarily addressed in the assessment phase, the nurse continues to monitor for allergic reactions throughout the client's care and promptly addresses any concerns that arise.

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A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take?

Nursing Test Bank

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