A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?
Advise the UAP to resume positioning the client on schedule.
Encourage the UAP to provide comfort care measures only.
Assume total care of the client to monitor neurologic function.
Assign a practical nurse to assist the UAP in turning the client.
The Correct Answer is A
Choice A: Advise the UAP to resume positioning the client on schedule.
Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.
Choice B: Encourage the UAP to provide comfort care measures only.
Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.
Choice C: Assume total care of the client to monitor neurologic function.
Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.
Choice D: Assign a practical nurse to assist the UAP in turning the client.
Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Waiting until after the procedure to assess for discomfort does not ensure client safety during the procedure itself. While pain assessment is important, it is not the priority safety intervention in this situation, especially since the client is already mildly confused and could disrupt the sterile field or injure themselves if not properly guided.
Choice B reason:Instructing a mildly confused client to keep their hands under the sterile field is likely to be ineffective and potentially dangerous. A confused client may not be able to follow or remember complex instructions, increasing the risk of contaminating the sterile field or causing injury. Instead, a nurse or assistant should physically stay near the client's hands to guide them.
Choice C reason: Pouring cleansing solution onto the sterile cloth field would contaminate the sterile setup, since fluids should only be poured into sterile containers or basins. This action could compromise the sterile field and increase infection risk, making it unsafe practice.
Choice D reason:Verification of informed consent is a critical safety intervention that must occur before any invasive procedure. Since the client is mildly confused, the nurse must ensure that the client had the capacity to consent or that a legal proxy provided it. Proceeding without verifying consent is a legal risk and violates the client's autonomy and safety protocols.
Correct Answer is B
Explanation
Choice A reason: While the fall is important, it is not the most immediate concern for the healthcare provider in the context of SBAR communication.
Choice B reason: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.
Choice C reason: The client's healthcare power of attorney is important for legal and consent purposes but is not the first piece of information to provide in an SBAR report.
Choice D reason: Currently prescribed medications are part of the background information and would follow after the immediate situation has been described.
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