A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted.
Which of the following actions should the nurse take?
Document the event in the client's progress notes.
Submit an incident report to the risk manager.
Inform the client of the APs' actions.
Tell the APs to stop the conversation.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.
Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.
Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.
Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B: Administer the medication to the toddler each evening.
Choice B rationale: Montelukast is a leukotriene receptor antagonist used for the long-term management of asthma, especially in preventing nighttime symptoms. It is typically prescribed to be administered once daily in the evening to provide optimal therapeutic benefits. By instructing the parents to give the medication each evening, the nurse promotes adherence to the prescribed dosing schedule and helps maximize the medication's effectiveness in controlling the toddler's asthma symptoms.
Choice A rationale: While some medications can be mixed with juice or other liquids to make them more palatable for children, montelukast should not be dissolved in a drink. Instead, it can be mixed with a spoonful of cold, soft food, such as applesauce or ice cream, if necessary, to facilitate administration. Mixing with juice could potentially alter the medication's efficacy or create an unpleasant taste.
Choice C rationale: Montelukast is not indicated for use as a quick-relief medication prior to physical activity. It is a maintenance medication intended for long-term asthma control rather than immediate relief of acute symptoms. Providing an additional dose of montelukast before physical activity would not serve the intended purpose and could increase the risk of side effects.
Choice D rationale: Montelukast is not meant to be used as a rescue medication for acute asthma attacks. It is a long-term control medication that helps prevent asthma attacks and improve overall symptom management. For acute asthma attacks, the toddler would require a fast-acting beta-agonist or other appropriate rescue medication prescribed by their healthcare provider. Administering montelukast during an acute asthma attack would not provide the rapid relief needed to alleviate symptoms and could potentially delay appropriate treatment.
Correct Answer is C
Explanation
Choice A rationale:
"Fidelity involves ensuring that we do no harm to the client." - This statement is not an accurate description of fidelity. Fidelity, in ethical terms, primarily refers to keeping promises and being loyal to clients, rather than preventing harm.
Choice B rationale:
"Fidelity involves making sure clients are able to make their own health care decisions." - While this statement relates to ethical principles, it is more closely associated with the principle of autonomy rather than fidelity. Fidelity is about keeping promises and being trustworthy.
Choice C rationale:
"Fidelity involves keeping promises made to clients." - This is the correct answer. Fidelity is the ethical principle that involves keeping commitments, promises, and agreements made to clients. It emphasizes the importance of honesty, trustworthiness, and integrity in the nurse-patient relationship.
Choice D rationale:
"Fidelity involves treating every client with the same level of respect." - While respecting clients is essential in nursing practice, this statement does not directly address the concept of fidelity. Fidelity is more about keeping promises and being loyal to individual clients rather than a uniform approach to all clients.
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