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.

Answer and Explanation

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.

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Correct Answer is ["B","C"]

Explanation

Rationale:

A. Respite care: Respite care provides temporary relief for caregivers, but it does not directly assist clients with limited financial resources in obtaining home IV therapy or covering medical costs. This resource may be helpful later but is not a primary financial support option.

B. Food stamps: Supplemental Nutrition Assistance Program (SNAP), or food stamps, helps low-income clients access adequate nutrition. Proper nutrition is important for healing and overall health, making this a relevant resource for a client below the poverty level.

C. Medicaid: Medicaid provides health coverage for low-income individuals and can help cover costs associated with home IV therapy, medications, and other healthcare needs. It is an appropriate recommendation for a client who meets income eligibility criteria.

D. Medicare Part A: Medicare primarily covers inpatient hospital care, skilled nursing facilities, hospice, and some home health services for clients over 65 or with certain disabilities. A young adult below the poverty level may not qualify, making this less appropriate for the scenario.

E. Adult day care: Adult day care provides socialization and supervision during the day, mainly for older adults or those with cognitive impairments. It does not address financial assistance or coverage for home IV therapy, so it is not a primary resource in this case.

A. Keep the foot in plantar flexion. B. Elevate the client's feet on pillows. C. Brace the foot with an ankle-foot orthotic. D. Perform passive range of motion of the ankle twice per day.

Correct Answer is C

Explanation

Rationale:

A. Keep the foot in plantar flexion: Maintaining the foot in plantar flexion increases the risk of developing foot drop by shortening the dorsiflexor muscles. This position does not support proper alignment or prevent contractures, making it counterproductive for prevention.

B. Elevate the client's feet on pillows: Elevating the feet may help reduce edema but does not prevent foot drop. It does not maintain proper dorsiflexion or support the ankle in a neutral position, so it is not effective for contracture prevention.

C. Brace the foot with an ankle-foot orthotic: An ankle-foot orthotic maintains the foot in a neutral position, preventing plantar flexion contractures and promoting proper alignment of the ankle. This intervention is highly effective for preventing foot drop in immobile clients by keeping the muscles and tendons stretched appropriately.

D. Perform passive range of motion of the ankle twice per day: Passive range of motion helps maintain joint mobility and circulation but alone may be insufficient to prevent foot drop. Consistent bracing or positioning is necessary to maintain neutral alignment when the client is not actively moving the ankle.

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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?

Nursing Test Bank

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A nurse is collaborating with social services in the discharge planning for a young adult client who is below the poverty income level and will require home IV therapy. Which of the following resources should the nurse recommend? (Select all that apply)

Correct Answer is ["B","C"]

Explanation

A nurse is caring for a client who is immobile. Which of the following interventions should the nurse add to the client's plan of care to prevent foot drop?

Correct Answer is C

Explanation

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