A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?
Evaluate why the client was not ambulated.
Ambulate the client on behalf of the AP.
Supervise the AP performing the task.
Remind the AP of her assigned tasks.
The Correct Answer is A
Rationale:
A. Evaluate why the client was not ambulated.: The first step in addressing a missed delegated task is to assess the reason it was not completed. Understanding whether barriers were related to the AP, client condition, workload, or communication helps the nurse plan corrective action and prevents recurrence.
B. Ambulate the client on behalf of the AP.: While ensuring the client’s needs are met is important, jumping straight to performing the task bypasses assessment of the underlying issue. Immediate action may address the symptom but not the cause of the missed delegation.
C. Supervise the AP performing the task.: Supervision is appropriate for ongoing tasks but is not the first action once a task has already been missed. The nurse must first determine why the task was not completed before implementing supervision.
D. Remind the AP of her assigned tasks.: Reminding the AP without assessing why the task was missed does not address potential systemic or situational barriers. It may be necessary later but is not the initial step in problem resolution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","G"]
Explanation
Rationale for correct findings:
• Hemoglobin 12 g/Dl: The client’s hemoglobin increased from 9.1 g/dL to 12 g/dL following the transfusion of 2 units of packed RBCs. This demonstrates improved oxygen-carrying capacity and correction of anemia, reflecting a positive response to the intervention.
• Hematocrit 36%: The rise in hematocrit from 27% to 36% indicates improved red blood cell volume and overall blood oxygenation. This laboratory improvement confirms that the transfusion effectively restored circulating red blood cells and addressed the client’s prior anemia.
• Blood pressure 112/74 mm Hg: The client’s blood pressure increased from 90/50 mm Hg to 112/74 mm Hg, suggesting improved hemodynamic stability. This indicates better perfusion and a positive response to both transfusion and supportive care.
• Heart rate 95/min: The decrease in heart rate from 118/min to 95/min reflects reduced compensatory tachycardia associated with anemia and hypovolemia. This demonstrates improved cardiovascular status following transfusion.
• Oxygen saturation 100% via 2 L/min nasal cannula: Oxygen saturation improved from 98% on room air to 100% on supplemental oxygen, indicating enhanced oxygen delivery and tissue perfusion. This is an objective sign of recovery from anemia and improved respiratory efficiency.
Rationale for incorrect findings
• Temperature 37.5°C (95°F): The temperature remained essentially unchanged and within normal limits. While important to monitor for infection or transfusion reactions, this finding does not reflect improvement in oxygen-carrying capacity or hemodynamic status.
• Respiratory rate 18/min: The respiratory rate remained stable and within normal limits. Although stability is positive, it does not directly reflect the improvements in hemoglobin, hematocrit, blood pressure, or oxygen saturation resulting from the transfusion.
Correct Answer is C
Explanation
Rationale:
A. Maintain sensory stimulation for the client: While in restraints, minimizing overstimulation is important to reduce agitation and prevent further aggressive behavior. Excessive sensory input can increase stress and escalate the situation rather than support safety.
B. Identify stressors that caused the client's aggression: Understanding triggers is important for long-term behavior management, but it is not the priority while the client is physically restrained. Immediate safety and monitoring take precedence over retrospective analysis.
C. Observe the client's range of movement: Continuous monitoring of the client’s range of motion is essential while restraints are in place to prevent injury, nerve damage, or impaired circulation. Regular checks ensure the restraints are applied safely and that the client maintains mobility as much as possible within safety limits.
D. Hold a critical incident debriefing about the client: Debriefing is important for staff learning and emotional processing after the event, but it occurs after the client is safe and restraints are removed. It is not an action to be performed while the client is restrained.
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