A nurse is observing an assistive personnel (AP) provide care to a group of clients. Which of the following actions by the AP requires intervention by the nurse?

Removing gloves before leaving an isolation room

Filling a basin with water at 40° C (104° F) when providing foot care

Instructing a client to look down at their feet when being assisted to ambulate

Applying water-soluble lubricant to the nares of a client who is receiving oxygen

Answer and Explanation

The Correct Answer is B

A. Removing gloves before leaving an isolation room is appropriate practice and helps prevent the spread of infection.
B. Filling a basin with water at 40° C (104° F) is too hot for foot care and could lead to burns or injury; water temperature for foot care should be comfortably warm, typically around 37°C (98.6°F).
C. Instructing a client to look down at their feet when being assisted to ambulate is a safety measure that can help the client maintain balance and avoid tripping.
D. Applying water-soluble lubricant to the nares of a client receiving oxygen is a standard practice to prevent dryness and does not require intervention.

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Correct Answer is B

Explanation

A. Keeping the water heater set below 60° C (140° F) is important for preventing scalding but may not be feasible for everyone, as some people prefer hotter water for hygiene.
B. Disposing of unused medications is a critical safety measure to prevent accidental ingestion or misuse, making it the best choice for home safety education.
C. Setting the refrigerator temperature to 7.2° C (45° F) is higher than the recommended maximum of 4° C (40° F) to prevent food spoilage and bacterial growth.
D. Running electrical cords under carpeting poses a fire hazard and should be avoided, thus is not suitable advice for a safety presentation.

A. Initiate oxygen therapy via nasal cannula for a client who has COPD. B. Initiate a 24-hr urine collection for a client who has end-stage kidney disease. C. Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus. D. Change the dressing for a client who has a decubitus ulcer.

Correct Answer is A

Explanation

A. Initiating oxygen therapy for a client with COPD is a priority because oxygenation is critical for clients with respiratory conditions. Hypoxia can lead to serious complications, making this intervention urgent.
B. While initiating a 24-hour urine collection is important for monitoring kidney function, it does not require immediate action compared to the need for oxygen therapy in a client with respiratory distress.
C. Administering antibiotics is essential, especially for a client with an infection like MRSA; however, the need for immediate oxygen therapy takes precedence over medication administration.
D. Changing the dressing for a decubitus ulcer is important for preventing infection and promoting healing but is not as time-sensitive as ensuring adequate oxygenation for the client with COPD.

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A nurse is observing an assistive personnel (AP) provide care to a group of clients. Which of the following actions by the AP requires intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

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