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 C
Explanation
Rationale:
A. "I will provide my child with high-fiber foods": While fiber is important for overall health, many high-fiber grains contain gluten, which must be avoided in celiac disease. Offering high-fiber foods without confirming they are gluten-free could cause intestinal damage and symptoms in the child.
B. "I will give my child whole wheat toast and milk for breakfast": Whole wheat contains gluten, which triggers an autoimmune response in children with celiac disease. Serving whole wheat toast is unsafe and indicates a misunderstanding of dietary restrictions for managing this condition.
C. "I will keep my child on a gluten-free diet": A strict gluten-free diet is the primary treatment for celiac disease. Eliminating all sources of wheat, barley, rye, and derivatives allows intestinal healing, prevents symptoms, and reduces the risk of long-term complications, showing correct understanding of dietary management.
D. "I will administer digestive enzymes with meals and snacks.": Digestive enzymes are not a standard treatment for celiac disease and do not prevent the autoimmune response caused by gluten. The focus should remain on dietary avoidance of gluten rather than relying on enzyme supplementation.
Correct Answer is B
Explanation
Rationale:
A. Use gauze to secure an arm board to the involved extremity: Using gauze alone to secure an arm board is not recommended for a PICC line, as it can cause pressure, restrict circulation, and does not provide adequate stabilization. Specialized securement devices or adhesive dressings are preferred to maintain catheter integrity and prevent complications.
B. Measure the arm circumference above the insertion site daily: Daily measurement of the arm circumference helps detect early signs of swelling, infiltration, or thrombophlebitis, which are potential complications of PICC lines. Monitoring for changes allows prompt intervention and helps ensure safe catheter function.
C. Schedule an MRI postprocedure to verify placement: MRI is not used to verify PICC placement. Catheter tip placement is typically confirmed with chest X-ray or fluoroscopy immediately after insertion, which is the standard method for ensuring correct placement in the superior vena cava.
D. Administer sedation for the procedure: PICC line insertion is generally performed under local anesthesia, not systemic sedation. Routine sedation is not indicated for this minimally invasive procedure unless the client has severe anxiety or special considerations, making it unnecessary in standard care.
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