A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take?

Complete an incident report.

Take the specimen to the laboratory.

Report the AP to the charge nurse.

Ask the AP about her concerns with the assignment.

Answer and Explanation

The Correct Answer is D

A.   Completing an incident report may be necessary if the refusal could potentially impact patient care or if there are policies or procedures in place that require documenting such incidents. It helps to document the details of the refusal and any subsequent actions taken.
B.   If the AP refuses to take the specimen, the nurse may need to take responsibility for ensuring the specimen is delivered to the laboratory promptly. This ensures that patient care activities are not delayed and that necessary diagnostic tests are performed in a timely manner.
C.   Reporting the refusal to the charge nurse or supervisor is appropriate, especially if there are concerns about the AP's behavior or if it is part of the facility's policy to escalate such incidents. The charge nurse can then address the situation and determine the appropriate course of action.

D.   Communicating with the AP to understand their concerns is essential. It allows the nurse to clarify any misunderstandings, address any issues or barriers the AP may have, and potentially resolve the situation collaboratively. It's important to listen to the AP's perspective and provide clarification or reassurance if needed.

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Correct Answer is C

Explanation

A. Metabolic acidosis is characterized by a decrease in bicarbonate or an increase in acids, which can be caused by conditions like kidney failure or diabetic ketoacidosis, but it is not typically associated with numbness and tingling.
B. Respiratory alkalosis is characterized by a high pH (>7.45) and a decreased PaCO2 (<35 mm Hg). It typically results from hyperventilation, which leads to excessive elimination of CO2 and subsequent alkalosis. This condition is less likely to occur in gastroenteritis unless there are other complicating factors such as anxiety or pain causing increased respiratory rate.
C. In the context of gastroenteritis, where there may be a loss of stomach acids through vomiting or diarrhea, the most likely acid-base imbalance would be metabolic alkalosis.
D. Respiratory acidosis is characterized by a low pH and an elevated PaCO2 (>45 mm Hg). It results from hypoventilation, leading to retention of CO2 and subsequent acidosis. Respiratory acidosis would not typically present with numbness and tingling in the extremities in the context of gastroenteritis.

A. Give the client aback massage. B. Teach the client relaxation techniques. C. Assist the client to cough and deep breathe ev D. Encourage the client to turn every 4 hr. E. Administer PRN analgesics as needed.

Correct Answer is ["A","B","C","E"]

Explanation

A. Postoperative patients often experience muscle tension and discomfort due to lying in one position for an extended period. A gentle back massage can help relieve muscle stiffness, promote relaxation, and improve circulation. It is a non-invasive comfort measure that can enhance the client's overall well- being.
B. Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques are beneficial postoperatively as they encourage relaxation and improve overall comfort.
C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) or pneumonia due to shallow breathing or inadequate lung expansion. Coughing and deep breathing exercises help to clear secretions, improve lung function, and prevent respiratory complications. It is typically recommended to perform these exercises every hour to maintain lung expansion and prevent complications.
D. Encouraging the client to turn every 2 hours (D), not every 4 hours, is essential to prevent pressure ulcers and promote circulation.
E. Postoperative pain management is essential for the client's comfort and recovery. Pain can interfere with the client's ability to cough, deep breathe, and move effectively, which may increase the risk of complications. Administering analgesics as needed helps to control pain, improve overall comfort, and promote participation in necessary activities such as coughing, deep breathing, and turning.

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A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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