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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The nurse wears an N95 respirator when performing client care: Measles is highly contagious and spreads through respiratory droplets. Wearing an N95 respirator provides appropriate respiratory protection for the nurse when caring for a client with measles. This action is appropriate and does not require intervention by the charge nurse.
B. The nurse places the client on airborne precautions: Measles is transmitted via airborne droplets, so placing the client on airborne precautions is necessary to prevent the spread of the disease to others. This action is appropriate and aligns with infection control guidelines.
C. The nurse ensures the client's room maintains a positive airflow: Positive airflow can potentially contribute to the spread of airborne pathogens outside the room, increasing the risk of transmission to others. For clients with airborne infections like measles, negative airflow rooms are required to minimize the risk of transmission to healthcare workers and other clients. Therefore, the charge nurse should intervene and correct this action.
D. The nurse has the client wear a mask for transport to radiology: Having the client wear a mask during transport helps minimize the spread of infectious droplets to others in the facility. This action is appropriate and aligns with infection control measures for airborne precautions
Correct Answer is B
Explanation
A. "Think about a positive outcome to a stressful situation." - This instruction describes a cognitive restructuring technique, which involves reframing negative thoughts with positive ones. While cognitive restructuring can be helpful for managing stress and anxiety, it is not specifically related to progressive relaxation.
B. "Tighten a muscle group, then release the tension and move to the next one." - This is the correct instruction for progressive relaxation. Progressive relaxation involves systematically tensing and relaxing muscle groups throughout the body to reduce physical tension and promote relaxation. By sequentially tensing and releasing muscle groups, the client learns to recognize and control muscle tension, which can help alleviate stress and anxiety.
C. "Focus on a pleasant memory and express your emotions in writing." - This instruction describes a journaling or expressive writing technique, which can be beneficial for processing emotions and reducing stress. However, it is not specific to progressive relaxation.
D. "Picture taking the stress you feel and pushing it down and out of your feet." - This instruction describes a visualization or imagery technique, where the client visualizes releasing stress from the body. While visualization can be a component of relaxation exercises, it is not specifically associated with progressive relaxation, which focuses on muscle tension and relaxation.
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