A nurse is reinforcing teaching with a newly licensed assistive personnel (AP) who has violated a client's confidentiality. Which of the following actions should the nurse take? (Select all that apply.)

Decline documenting the first counseling session.

Communicate expected behavior to the AP.

Explain to the AP the consequences of the behavior.

Allow the AP time to respond to the counseling information.

Conduct the counseling session with another AP present.

Answer and Explanation

Correct Answer : B,C,D

A.   Decline documenting the first counseling session: Documentation is necessary to maintain accurate records of counseling sessions.
B.   Communicate expected behavior to the AP: Reinforcing the expectations helps clarify appropriate behavior.
C.   Explain to the AP the consequences of the behavior: Understanding potential consequences encourages adherence to confidentiality standards.
D.   Allow the AP time to respond to the counseling information: Allowing the AP to respond fosters a two-way communication approach and encourages accountability.
E.   Conduct the counseling session with another AP present: Counseling sessions should remain private to maintain confidentiality.

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Correct Answer is B

Explanation

A. Perform a specific nursing task for a group of clients: This approach aligns more with functional nursing, not total patient care.
B. Provide complete care for a caseload of clients: In total patient care, the nurse is responsible for all aspects of care for a specific group of clients during their shift.
C. Receive cross-training in multiple departments: Cross-training is related to float pool or department-specific training, not the care delivery method.
D. Delegate low-skilled tasks to assistive personnel: While delegation may occasionally occur, the focus in total patient care is on the nurse providing direct care.

A. The medication administration record indicates the client received pain medication 12 hr ago. B. The client reports a pain level of 7 on a scale from 0 to 10. C. The client's pulse rate and blood pressure have decreased. D. The client is restless and grimaces with movement. E. The client's family tells the nurse the client is in pain.

Correct Answer is ["A","B","C","D"]

Explanation

A. The medication administration record indicates the client received pain medication 12 hr ago. This is important to prevent overmedication and assess if the dosing schedule allows another administration.
B. The client reports a pain level of 7 on a scale from 0 to 10. Pain rating is a critical factor in deciding whether to administer PRN pain medication.
C. The client's pulse rate and blood pressure have decreased. Vital sign changes may indicate sedation or hemodynamic instability, which could contraindicate additional pain medication.
D. The client is restless and grimaces with movement. Nonverbal cues of pain are essential considerations, especially if the client is unable to communicate effectively.
E. The client's family tells the nurse the client is in pain. While family input can be valuable, pain assessment should be based on the client's report or nurse observations.

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A nurse is reinforcing teaching with a newly licensed assistive personnel (AP) who has violated a client's confidentiality. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working on a medical-surgical unit that uses the total patient care delivery method. For each shift, the nurse should plan to take which of the following actions?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse consider before administering the prescribed PRN pain medication? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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