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 B

Explanation

A. Take antacids that contain mint for heartburn. - This statement is incorrect. While antacids can help neutralize stomach acid and relieve heartburn symptoms, antacids containing mint can relax the lower esophageal sphincter (LES), leading to increased reflux symptoms. Therefore, clients with GERD should avoid antacids containing mint.
B. Avoid consuming foods containing chocolate. - This statement is correct. Chocolate is a common trigger for GERD symptoms due to its high fat content, which can relax the LES and delay stomach emptying, leading to increased acid reflux. Advising the client to avoid foods containing chocolate can help minimize GERD symptoms.
C. Increase dietary intake of citrus fruits. - This statement is incorrect. Citrus fruits are acidic and can exacerbate GERD symptoms by increasing stomach acid production and irritating the esophagus. Therefore, clients with GERD should limit or avoid citrus fruits to reduce acid reflux.
D. Lie down for 30 min after eating a meal. - This statement is incorrect. Lying down after eating can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus more easily. Instead, clients with GERD should remain upright for at least 2-3 hours after eating to help prevent acid reflux.

A. "Did anything in particular make you feel this way?" B. "Do you ever think about harming yourself?" C. "How long have you had these feelings of uselessness?" D. "Would you tell me more about the changes you see in your body?"

Correct Answer is B

Explanation

A. "Did anything in particular make you feel this way?" - While exploring potential triggers for the client's feelings of uselessness is important, assessing for suicidal ideation takes precedence. However, this question can be asked after addressing the immediate safety concern.
B. "Do you ever think about harming yourself?" - This is the priority assessment question. Older adults experiencing feelings of uselessness and worthlessness may be at risk for suicidal ideation or self-harm. Asking about thoughts of self-harm allows the nurse to assess the client's safety and determine the need for immediate intervention.
C. "How long have you had these feelings of uselessness?" - While understanding the duration of the client's feelings is relevant, assessing for suicidal ideation is more critical in ensuring the client's safety.
D. "Would you tell me more about the changes you see in your body?" - Exploring the client's perception of physical changes is important for addressing body image concerns and promoting self-esteem. However, assessing for suicidal ideation takes precedence as it addresses the client's immediate safety.

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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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