Question

While the nurse irrigates a client's NG tube, an LPN/LVN approaches the nurse to report that a different client is hemorrhaging from the rectum. Which action by the nurse is most appropriate?

A) Instruct the LPN/LVN to take over the irrigation of the NG tube while the nurse assesses the other client.
B) Manage the bleeding client and then discuss with the LPN/LVN why this was a Health Insurance Portability and Accountability Act (HIPPA) violation.
C) Ask the LPN/LVN to obtain the client's vital signs and immediately report them.
D) Tell the LPN/LVN to find another nurse and report about the client's difficulties.

Answer 1

The nurse should ask the LPN/LVN to obtain the hemorrhaging client's vital signs and immediately report them, as this information is essential for timely and appropriate care. The nurse can then properly assess and address the hemorrhage, which is a more urgent concern than the NG tube irrigation.

Step-by-step explanation:

The most appropriate action for the nurse when notified by an LPN/LVN that a different client is hemorrhaging from the rectum would be to instruct the LPN/LVN to obtain the client's vital signs and immediately report them (option C). The nurse is responsible for managing serious and potentially life-threatening situations, such as a hemorrhaging client, which require immediate assessment and intervention. The client with the NG tube irrigation is also important, but the hemorrhage is a more urgent matter needing direct supervision and could lead to critical complications if not promptly addressed.

By asking the LPN/LVN to obtain vital signs, the nurse ensures that while they are addressing the emergency, crucial information is being gathered that will help in assessing the condition and severity of the hemorrhage. The information that the LPN/LVN provides can guide the nurse in providing appropriate and timely care to the hemorrhaging client. It is also not mentioned that there is any issue regarding HIPAA violation in this scenario, so option B is not relevant.