A charge nurse witnesses an assistive personnel (AP) failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first?
Notify the unit manager about the incident.
Alert the infection control department.
Discuss the issue with the AP.
Reinforce facility protocols at the next staff meeting.
The Correct Answer is C
A. Notifying the unit manager should happen but discussing the issue with the AP directly is the initial step in addressing the problem.
B. Alerting the infection control department is important, but direct communication with the AP should come first to address the immediate concern.
C. Speaking with the AP allows for immediate clarification and correction of the behavior, aiming to prevent further incidents.
D. Reinforcing facility protocols at a staff meeting is beneficial, but immediate correction at the individual level is more crucial to prevent recurrence of the issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is not the highest priority because this is a chronic condition that does not pose an
immediate threat to the client's health. The nurse should monitor the client's circulation, provide education on foot care, and encourage smoking cessation if applicable.
B. This client is at risk for urinary retention, which can lead to bladder distension,
infection, and renal damage. The nurse should assess the client's bladder, perform a
bladder scan, and notify the provider if indicated. This is the most urgent situation that requires immediate intervention.
C. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is not the highest priority because this is a planned procedure that does not require immediate action. The nurse should prepare the client for chemotherapy, provide emotional support, and teach the client about potential side effects and complications.
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an
axillary temperature of 38° C (101° F) is not the highest priority because this is a sign of infection that can be managed with antibiotics and infection control measures. The nurse should administer the prescribed antibiotics, monitor the client's vital signs, and
implement contact precautions.
Correct Answer is D
Explanation
A. While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B. Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C. Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D. Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.
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