A nurse is caring for a client and notices fraying on the electrical cord of the client fall. The charge nurse should identify that which of the following nurse to take?

A. A nurse withholds nutrition from a client who has a do-not-resuscitate (DNR) order:

Withholding nutrition from a client solely based on a DNR order may not align with ethical practice, as nutrition should be provided unless there are specific contraindications or the client has expressed wishes to withhold nutrition.
B. A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min: This is the correct answer. Ethical practice involves providing comfort measures, including appropriate pain management, to clients who are terminally ill and experiencing pain or distress, even if it may inadvertently decrease the respiratory rate.
C. A nurse elects not to care for a client who had an abortion: Refusing to care for a client based on personal beliefs or judgments about their medical history or decisions may not align with
ethical practice, as nurses have a professional obligation to provide nonjudgmental care to all clients.
D. A nurse raises all four side rails on the bed of a client who is confused: While ensuring client safety is important, raising all four side rails without considering the client's individual needs and preferences may not be ethical practice, as it may infringe on the client's autonomy and dignity.

A. Discuss the issue with the AP: This is the correct answer. Addressing the issue directly with the AP allows for immediate clarification of expectations and correction of behavior. It also provides an opportunity to understand any factors contributing to the deviation from protocol.
B. Reinforce facility protocols at the next staff meeting: While reinforcing facility protocols is important, addressing the issue directly with the individual involved should be the first step to ensure timely resolution and prevent further occurrences.
C. Notify the unit manager about the incident: Notifying the unit manager may be necessary if further action is required or if the issue cannot be resolved at the staff level. However, addressing the issue directly with the AP should be the initial step.
D. Alert the infection control department: Involving the infection control department may be necessary if there are concerns about potential infection control risks. However, discussing the issue with the AP allows for immediate action and clarification of expectations.