A charge nurse is observing an assistive personnel perform delegated tasks.
Which of the following actions by the AP requires the charge nurse to intervene?

Providing postmortem care for a client who has recently died.

Performing a simple dressing change on a client's foot.

Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile.

Emptying an indwelling urinary catheter bag for a client while wearing clean gloves.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.

Choice B rationale:

Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.

Choice C rationale:

Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is not sufficient. Alcohol is not effective against C. Difficile spores.

Choice D rationale:

Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.

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Correct Answer is C

Explanation

Choice A rationale:

Activating the fire alarm system is the second action the nurse should take after rescuing the individuals in the area.

Choice B rationale:

Obtaining and using a fire extinguisher should only be attempted by personnel trained to do so. Using a fire extinguisher incorrectly can escalate the fire or cause harm to individuals in the vicinity. The priority is to evacuate and let trained personnel handle the fire.

Choice C rationale:

Evacuating clients from the area is an essential and immediate step. Evacuation ensures the safety of everyone in the area, preventing potential harm due to smoke inhalation or fire spread.

Choice D rationale:

Closing the doors and windows on the unit can help contain the fire and prevent its spread. However, this action should be taken after activating the fire alarm system and initiating the evacuation process. Closing doors and windows can buy some time and limit the fire's oxygen supply, but it should not delay the evacuation procedure.

A. Irritability. B. Hypotonicity. C. Decreased auditory startle response. D. Increased head circumference.

Correct Answer is A

Explanation

Choice A rationale:

Irritability is a common withdrawal symptom in newborns exposed to cocaine during pregnancy. Cocaine exposure can lead to irritability, restlessness, and difficulty in consoling the newborn.

Choice B rationale:

Hypotonicity, or decreased muscle tone, is not a common finding associated with cocaine exposure in newborns. Cocaine exposure more commonly results in hypertonicity, where the muscles are tense and rigid.

Choice C rationale:

Decreased auditory startle response is not a typical finding associated with cocaine exposure. Newborns exposed to cocaine may have an exaggerated startle response, which is the opposite of the expected finding in this case.

Choice D rationale:

Increased head circumference is not a characteristic finding associated with cocaine exposure. Cocaine exposure is more likely to cause growth restriction, low birth weight, and microcephaly (small head size) in newborns.

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A charge nurse is observing an assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?

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A charge nurse is observing an assistive personnel perform delegated tasks.
Which of the following actions by the AP requires the charge nurse to intervene?