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

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

Providing postmortem care for a client who has recently died

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

Answer and Explanation

The Correct Answer is B

A. Performing a simple dressing change on a client's foot - This action is appropriate and within the scope of practice for assistive personnel.
B. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile - Handwashing with alcohol-based hand rub is not effective against Clostridium difficile spores. Proper hand hygiene for C. difficile requires washing with soap and water. The charge nurse should intervene to correct this action and ensure proper infection control procedures are followed.
C. Providing postmortem care for a client who has recently died - Providing postmortem care is within the scope of practice for assistive personnel and is appropriate.
D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves - This action is appropriate and within the scope of practice for assistive personnel.

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Correct Answer is D

Explanation

A. Holding a vibrating tuning fork 1 to 2 cm from the child's ears is not a part of the Weber's test procedure. The Weber's test involves assessing lateralization of sound in cases of unilateral hearing loss. Placing the tuning fork close to the ears may interfere with the accuracy of the test.
B. Measuring the amount of time the child can hear the sound is not relevant to the Weber's test. This action does not assess lateralization of sound but rather evaluates the duration of hearing.
C. Obtaining a tympanogram reading is not necessary before initiating the Weber's test. Tympanometry is a separate test used to assess the function of the middle ear, particularly the movement of the eardrum and the conduction bones.
D. Placing a vibrating tuning fork on the top of the child's head is the correct action for performing the Weber's test. During this test, the nurse activates a tuning fork and places it on the midline of the child's head or forehead. The child is asked if they hear the sound equally in both ears or if it is louder in one ear than the other. This helps determine if there is asymmetrical hearing loss.

A. Diaphoresis B. Fever C. Polyuria D. Diarrhea

Correct Answer is B

Explanation

A. Diaphoresis: Diaphoresis, or excessive sweating, is a common side effect of clozapine and may not necessarily indicate a need for immediate intervention. However, it should be documented and monitored for any changes.
B. Fever: Fever can be a sign of infection, which is a serious concern in clients taking clozapine due to the risk of agranulocytosis, a potentially life-threatening side effect characterized by a severe decrease in white blood cell count. Any signs of infection, including fever, should be reported promptly to the provider for further evaluation and management.
C. Polyuria: Polyuria, or excessive urination, is not typically associated with clozapine use and may be indicative of other underlying issues such as diabetes mellitus or diabetes insipidus. While it should be assessed and managed appropriately, it is not specifically related to clozapine administration and may not require immediate reporting to the provider.
D. Diarrhea: Diarrhea is a common gastrointestinal side effect of clozapine and may occur due to its effects on the gastrointestinal system. While persistent or severe diarrhea should be monitored and managed, it is not typically considered a serious adverse reaction that requires immediate reporting to the provider unless it is accompanied by other concerning symptoms.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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