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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ecchymoses (bruising) over the buttocks and lower back in an older adult could be a sign of physical abuse or an underlying bleeding disorder, and it should be reported immediately.
B. Hirsutism, or increased facial and chest hair, is a common age-related change and does not usually require reporting unless it indicates an endocrine disorder.
C. Reduced skin elasticity is a normal age-related finding due to decreased collagen and elastin in aging skin.
D. Increased macules, or age spots, are benign and typical with aging, especially with prolonged sun exposure, and do not require reporting.
Correct Answer is B
Explanation
A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.
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