A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

Elevates the head of the client's bed to 30° before inserting a nasogastric tube

Assists the client into a fetal position on his side in preparation for a lumbar puncture

Assesses the client's gag reflex following an esophagogastroduodenoscopy

Maintains the chest tube collection device below the level of the insertion site when ambulating the client

Answer and Explanation

The Correct Answer is A

Choice A Reason:
The patient should be elevated 45-90° before inserting a nasogastric tube helps prevent aspiration and facilitates tube insertion.
Choice B Reason:
Assisting the client into a fetal position on his side in preparation for a lumbar puncture is a proper positioning technique to facilitate the procedure and minimize discomfort for the client.
Choice C Reason:
Assessing the client's gag reflex following an esophagogastroduodenoscopy (EGD) is standard practice to ensure the client's safety and ability to protect their airway after the procedure.
Choice D Reason:
Maintains the chest tube collection device below the level of the insertion site when ambulating the client is correct. Chest tube management is critical to prevent complications such as air leaks, tension pneumothorax, and tube dislodgement. When ambulating a client with a chest tube, it's essential to keep the collection device below the level of the insertion site to ensure proper drainage and prevent air from entering the pleural space. If the collection device is positioned above the insertion site, it could result in fluid or air backflow into the patient's chest cavity, which can lead to complications.

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Correct Answer is A

Explanation

Choice A Reason:
"I will have a client who is on airborne precautions wear a mask when out of her room." This statement demonstrates understanding of airborne precautions. Clients on airborne precautions, such as those with tuberculosis or measles, should wear a mask when they leave their room to prevent the spread of infectious droplets.
Choice B Reason:
"I will place a client who has compromised immunity in a negative-pressure airflow room." While placing a client with compromised immunity in a negative-pressure airflow room may be appropriate in some cases to reduce the risk of exposure to pathogens, it is not a standard precaution and is not applicable to all clients with compromised immunity.
Choice C Reason:
"I will instruct visitors to wear a mask when visiting a client who is on contact precautions." This statement indicates an understanding of contact precautions. Visitors should wear appropriate personal protective equipment, such as gloves and gowns, when visiting clients on contact precautions to prevent the transmission of infectious agents.
Choice D Reason:
"I will wear an N95 respirator mask when caring for a client who is on droplet precautions." This statement demonstrates understanding of droplet precautions. Healthcare providers should wear a surgical mask when caring for clients on droplet precautions, as it helps prevent the transmission of respiratory droplets generated by the client through coughing, sneezing, or talking. N95 respirator masks are typically reserved for airborne precautions.

A. Reinforce facility protocols at the next staff meeting. B. Discuss the issue with the AP. C. Alert the infection control department. D. Notify the unit manager about the incident.

Correct Answer is B

Explanation

Choice A Reason:
Reinforcing facility protocols at the next staff meeting, is important for reminding all staff members of the importance of following protocols, but it may not address the immediate issue at hand.
Choice B Reason:
Discussing the issue with the AP is correct. When a charge nurse witnesses an assistive personnel (AP) failing to follow facility protocol, the first action should be to directly address the issue with the AP. This allows for immediate feedback and correction of behavior, helping to ensure that proper procedures are followed in the future.
Choice C Reason:
Alerting the infection control department, may be necessary if the violation poses a risk of infection transmission, but it may not be the first step. Directly addressing the issue with the AP allows for immediate correction and prevents potential harm.
Choice D Reason:
Notifying the unit manager about the incident, is also important, but addressing the issue with the AP directly is the immediate action needed to correct the behavior.

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A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

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