The nurse manager has delegated four clients to be cared for by a licensed practical/vocational nurse (LPN/LVN). Which actions by the LPN/LVN evaluated by the delegating nurse may indicate disciplinary action should be instituted? Select all that apply.
The LPN documented wound care that was not performed.
The LPN/LVN takes an extra 15 minutes of lunchtime with a co-worker.
The LPN left unused dressing supplies in the client's room.
A client's blood pressure is 220/114 mmHg and the prescribed antihypertensive was not administered.
A client refuses to take medication that is prescribed.
Correct Answer : A,D
Choice A rationale
Falsifying documentation is a severe ethical and legal violation that directly undermines patient safety and professional integrity. When a nurse records that a treatment was completed when it was not, it creates a false medical record that can lead to inappropriate clinical decisions by the rest of the healthcare team. This act of dishonesty is considered professional misconduct and typically warrants immediate disciplinary action by the licensing board and the employing institution.
Choice B rationale
While taking an extended lunch break may be a performance or productivity issue, it is generally handled through internal human resources policies or verbal warnings rather than formal disciplinary action by a nurse manager. This behavior does not necessarily constitute a clinical safety risk or a violation of the nursing practice act in the same way that clinical negligence or falsification of records does. It is usually addressed through standard workplace time management protocols.
Choice C rationale
Leaving unused supplies in a room is a minor breach of efficiency or infection control standards but does not rise to the level of professional disciplinary action. While it may lead to waste or clutter, it is an easily corrected habit that is typically managed through simple feedback or coaching. It does not demonstrate a lack of competence or a willful intent to harm, nor does it violate the core ethical duties of nursing.
Choice D rationale
Failing to administer a critical medication when a patient is experiencing a hypertensive crisis, defined as a blood pressure > 180/120 mmHg, represents a significant failure in clinical judgment and a breach of the standard of care. This omission can lead to life-threatening complications such as stroke or organ failure. Normal blood pressure is < 120/80 mmHg. Neglecting such an extreme reading requires formal investigation and potentially severe disciplinary consequences to ensure safety.
Choice E rationale
Patients have the legal and ethical right to refuse medical treatment or medications under the principle of autonomy. If a nurse respects a patient's refusal, documents it correctly, and notifies the provider, they are practicing within their professional scope. This action is not a cause for disciplinary measures because the nurse is upholding the rights of the individual. It is the nurse's responsibility to educate the patient, but they cannot force compliance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Step 1 is 8 mg ÷ 10 mg × 1 mL.
Step 2 is 0.8 mL. The correct answer is 0.8.
Correct Answer is C
Explanation
Choice A rationale
Ensuring an area is completely free of all microorganisms, including spores, describes surgical asepsis or sterilization rather than medical asepsis. Surgical asepsis is required for invasive procedures like surgery or catheterization to prevent any microbial entry into sterile body cavities. Medical asepsis, often referred to as clean technique, acknowledges the presence of some non-pathogenic microbes while focusing on the reduction of the overall microbial load and the elimination of specific pathogens.
Choice B rationale
Administering prophylactic antibiotics is a pharmacological intervention used to prevent infection in high-risk scenarios, but it is not a definition or primary goal of medical asepsis. Medical asepsis refers to physical and procedural actions, such as hand hygiene and environmental cleaning, designed to interrupt the chain of infection. Relying on antibiotics does not address the mechanical transfer of pathogens between individuals or objects, which is the core focus of aseptic nursing practice.
Choice C rationale
The primary goal of medical asepsis is to limit the spread of microorganisms by reducing their number and preventing their transfer. This involves practices like handwashing, using gloves when appropriate, and cleaning surfaces. By maintaining a clean environment and following standard precautions, healthcare providers protect themselves and their clients from healthcare-associated infections. This technique is used in daily care to manage the microbial environment without the total elimination required in sterile fields.
Choice D rationale
Destroying all microorganisms, including highly resistant bacterial spores, is the definition of sterilization. Sterilization is a component of surgical asepsis, achieved through methods like autoclaving or chemical sterilants. Medical asepsis does not reach this level of microbial destruction; it aims to keep the environment clean and safe by controlling the population of pathogenic organisms. Normal flora may remain on surfaces under medical asepsis, whereas sterilization leaves a surface entirely void of life.
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