A charge nurse witnesses assistive personnel failing to follow facility protocol when discarding contaminated lines. Which of the following actions should the nurse take first?

Alert the infection control department

Discuss the issue with the AP

Reinforce facility protocols at the next staff meeting

Notify the unit manager about the incident

Answer and Explanation

The Correct Answer is B

a.   While alerting the infection control department is important, directly addressing the issue with the involved personnel should be the initial action.
b.   Discussing the issue with the assistive personnel (AP) allows for immediate clarification of the protocol and provides an opportunity to correct the behavior.
c.   Reinforcing facility protocols at a staff meeting may be necessary but should not be the first step when immediate action is required.
d.   Notifying the unit manager is important, but addressing the issue with the AP directly is the first step in resolving the situation and preventing future occurrences.

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Correct Answer is B

Explanation

a. Administering a sedative should not be the first response, as it may not address the underlying cause of the behavior and may increase the risk of adverse effects.
b. Contacting a family member to provide support and comfort to the client can help alleviate agitation and may help redirect the client's behavior.
c. Placing the client in a wheelchair with a lap tray does not address the underlying cause of the behavior and may not be effective in managing agitation.
d. Keeping the client in her room with the door closed may isolate the client but does not address the underlying cause of the behavior or provide appropriate support.

A. A primigravida client who is one day postoperative following a cesarean section and has a PCA pump B. A multigravida client who has preeclampsia and is receiving misoprostol for the induction of labor C. A client who has gestational diabetes and is receiving biweekly nonstress tests D. A client who is at 32 weeks gestation and has premature rupture of membranes

Correct Answer is A

Explanation

a. Postoperative care, especially for a client with a PCA pump (Patient-Controlled Analgesia), requires skills commonly found in medical-surgical units, making it suitable for an RN with experience in that area.
b. Managing preeclampsia and labor induction involves obstetric-specific knowledge and skills, which are better suited for a nurse with experience in obstetrics.
c. Gestational diabetes management and nonstress tests are part of routine obstetrical care and do not necessarily require specialized medical-surgical skills.
d. A client with premature rupture of membranes at 32 weeks gestation requires close monitoring and potentially specialized obstetric care, not typically provided by medical-surgical nurses.

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A charge nurse witnesses assistive personnel failing to follow facility protocol when discarding contaminated lines. Which of the following actions should the nurse take first?

Nursing Test Bank

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