A nurse is assessing a client who is experiencing profuse vomiting.

Upon admission, the client's vital signs were within the expected reference range, but now the client's blood pressure is 86/58 mm Hg, his pulse is 114/min and weak, and his respiratory rate is 27/min.

The client appears restless and anxious and states that he thinks he is dying.

Which of the following actions should the nurse take first?

Choice A rationale

Determining the accepted standards for hand hygiene is the first and most critical step in an audit. Without a clear set of criteria, there is no basis for evaluating current practices. This standard serves as a benchmark against which all subsequent data will be measured, ensuring the audit is objective and that any deviations can be accurately identified.

Choice B rationale

Establishing data collection methods is a crucial step, but it must follow the establishment of standards. The methods for data collection, such as direct observation or surveys, must be designed to accurately measure adherence to the predetermined standards. Without standards, the data collected would lack context and a meaningful reference point for analysis.

Choice C rationale

Comparing facility data to established criteria is a subsequent step in the audit process. It involves analyzing the collected data to determine whether current practices align with the accepted standards. This comparison identifies gaps in compliance, but it can only be done after the standards have been defined and data has been collected.

Choice D rationale

Corrective measures are a final step in the quality improvement cycle. They are implemented after data has been collected, analyzed, and a need for change has been identified. Taking corrective action before an audit is completed would be premature and lacks an evidence-based foundation, potentially leading to ineffective or misdirected interventions. *.

Choice A rationale

Reporting the observation to the immediate supervisor is the most appropriate and ethical action. The nurse is a mandated reporter for such events within the healthcare setting. The supervisor, in their administrative role, is responsible for initiating a formal investigation into the matter, ensuring due process, and taking necessary disciplinary action according to institutional policy. This approach protects both the client and the nurse, who is acting on observed evidence, and maintains a chain of command.

Choice B rationale

Confronting the assistive personnel (AP) directly is an inappropriate and potentially unsafe action. This approach could escalate the situation, lead to a hostile confrontation, and create an unsafe work environment. The nurse's role is not to act as a law enforcement officer or to administer disciplinary action. The proper channel for addressing a suspected theft is through the established reporting structure, which involves informing the immediate supervisor. This maintains professional boundaries and ensures a fair and impartial investigation.

Choice C rationale

Telling the client that the assistive personnel (AP) took their watch is premature and unprofessional. The nurse has only observed the AP with a watch, but has not yet confirmed it is the client's. Making such an accusation directly to the client could be slanderous, cause emotional distress, and is not a factual statement. The proper procedure is to report the observation to the supervisor and allow the official investigation to proceed, which will determine the facts before any conclusions are drawn or communicated.

Choice D rationale

Calling security before the assistive personnel (AP) leaves the building is an excessive and premature action. The nurse's role is to report concerns to the immediate supervisor, who will then follow the proper institutional procedures, which may include contacting security if deemed necessary. Bypassing the chain of command and taking unilateral action could create a chaotic and unmanaged situation, potentially infringing on the AP's rights. The supervisor is the designated authority to manage such incidents and coordinate with other departments as needed. *.