The licensed practical/vocational nurse is caring for a client who is of the Mormon faith. The nursing assistant (NA) is providing delegated interventions. The nurse should intervene if the NA:
A) makes the client's bed while she is walking in the hall.
B) knocks on the client's door before bringing the lunch tray.
C) enters the client's room to take vital signs when the two elders from the church are visiting.
D) reports to the nurse the fingerstick blood sugar results.
Ans: C
Feedback:
The nurse should intervene when seeing the NA enters the client's room to take vital signs when the two elders are from the church because the client needs privacy during these visits. The nurse needs to privately talk to the NA and emphasize that the NA knock on a client's door and gain permission before entering, so that if the client is having a visit from her church, or wants privacy, that the client's rights are not violated. The other listed interventions are acceptable actions for the NA to perform.
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