A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?
Tell the AP to list the steps of the task.
Instruct the AP to report back once the task is complete.
Ask the family if the AP performed the task correctly.
Request the AP to provide a return demonstration of the task.
The Correct Answer is D
A. Telling the AP to list the steps of the task is not sufficient to ensure correct performance. It may show knowledge of the steps, but it does not ensure the AP is performing the task correctly or safely.
B. Instructing the AP to report back once the task is complete does not allow the nurse to actively observe the AP’s technique or provide feedback on performance.
C. Asking the family if the AP performed the task correctly may provide subjective input, but the nurse is responsible for assessing and ensuring the proper completion of nursing tasks.
D. Requesting the AP to provide a return demonstration of the task is the best method. This allows the nurse to directly observe the AP’s technique, correct any errors, and ensure that the task is performed according to the prescribed standards. This also serves as a valuable teaching opportunity.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Wear sterile gloves when in contact with body fluids" is incorrect. While sterile gloves are necessary for sterile procedures, clean gloves are generally sufficient for contact with body fluids. The main focus of hand hygiene is on proper handwashing techniques.
B. "Use alcohol-based cleanser when hands are visibly soiled" is incorrect. Alcohol-based hand sanitizers should not be used when hands are visibly soiled, as they are less effective in removing dirt, grease, or organic material. Soap and water are needed for visibly soiled hands.
C. "Wash hands with soap and water for 20 seconds" is correct. The recommended duration for handwashing is 20 seconds, which is sufficient for removing pathogens effectively. This is standard practice for maintaining proper hand hygiene in healthcare settings.
D. "Artificial nails can be worn when performing direct client care" is incorrect. Artificial nails and chipped nail polish are contraindicated in healthcare settings because they can harbor bacteria and increase the risk of infection transmission.
Correct Answer is B
Explanation
A. Anorexia: This is not a common or serious adverse effect of heparin. It is not usually a priority for reporting to the provider.
B. Epistaxis: This is correct. Heparin is an anticoagulant, and one of the major risks associated with its use is bleeding. Epistaxis (nosebleeds) is a common sign of bleeding that could be a result of heparin therapy, and it should be reported to the provider promptly.
C. Bradycardia: Bradycardia is not a common adverse effect of heparin. Heparin primarily affects clotting mechanisms, not heart rate.
D. Weight gain: Weight gain is not a typical adverse effect of heparin. If the weight gain is significant or linked to fluid retention, it may need to be assessed, but it is not a typical reaction to heparin.
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