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 D

Explanation

Choice A rationale:

Instructing the client to "Lie down for 30 min after meals" is an inappropriate recommendation for managing heartburn during pregnancy. Lying down after meals allows stomach acid from flowing back into the esophagus, worseningheartburn symptoms.

Choice B rationale:

Eating a high-fat snack at bedtime is not advisable for managing heartburn. Fatty foods can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus and worsen heartburn symptoms. Avoiding high-fat snacks close to bedtime is a more appropriate recommendation.

Choice C rationale:

Sipping carbonated beverages throughout the day can exacerbate heartburn symptoms. Carbonated beverages, including sodas and sparkling water, can increase stomach acid and contribute to heartburn. Therefore, advising the client to avoid carbonated beverages is more appropriate for managing heartburn during pregnancy.

Choice D rationale:

Drinking hot herbal tea alleviates the heartburn symptoms and is recommended in pregnancy.

A. Human papillomavirus (HPV) B. Rotavirus. C. Diphtheria, tetanus, and acellular pertussis (DTaP) D. Herpes zoster.

Correct Answer is D

Explanation

Choice A rationale:

Human papillomavirus (HPV) vaccination is recommended for adolescents and young adults to prevent HPV-related cancers and diseases. However, in the context of older adults, especially those who are not previously vaccinated, the priority shifts to other immunizations that are more relevant to their age group.

Choice B rationale:

Rotavirus vaccination is administered to infants to protect against rotavirus infections, which can cause severe diarrhea and dehydration. It is not a priority immunization for older adults. Older adults are at higher risk for certain diseases, and their immunization focus should be on vaccines that prevent those specific conditions.

Choice C rationale:

Diphtheria, tetanus, and acellular pertussis (DTaP) vaccination is essential for children and adults, especially for those who have not received a complete series of vaccinations. However, the question specifies older adults, and DTaP is typically administered to children. While it is crucial for healthcare providers and family members to stay up-to-date with their vaccinations, other immunizations are more pertinent for older adults.

Choice D rationale:

Herpes zoster vaccination (shingles vaccine) is recommended for adults aged 50 years and older. Herpes zoster is a painful rash caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. Older adults are at higher risk of developing shingles, and vaccination can reduce the likelihood of the disease and its complications. Therefore, the nurse should recommend the herpes zoster vaccine to the group of older adults as it aligns with their age and addresses a specific health risk they face.

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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?