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 C,D,A,B
Explanation
A. The statement detailing the temperature of 39.5 degrees C (103.1 degrees F) represents the Assessment (A) phase, where the nurse shares the objective physical findings and clinical measurements gathered during the client evaluation. This logically follows the background context.
B. Requesting a prescription for a sputum culture represents the Recommendation (R) phase, which is the final step of the communication framework. In this phase, the nurse proposes a specific action or intervention to the provider to address the identified problem.
C. The statement regarding the report of increasing shortness of breath represents the Situation (S) phase, which must be presented first. This step establishes the immediate reason for the communication and states the current clinical problem.
D. The statement noting that the client has COPD represents the Background (B) phase, which is the second step. This provides the essential clinical history and context surrounding the client to help the provider understand the underlying factors related to the current situation.
Correct Answer is D
Explanation
A. Consulting the ethics committee is unnecessary at this stage, as there is no ethical dilemma in arranging social support services.
B. Suggesting a discharge delay is premature and may not be feasible; alternative support should be considered first.
C. Long-term care facility placement is a more permanent solution and may not align with the client’s needs or preferences.
D. Recommending a referral to social services is appropriate as social services can help arrange post-discharge support, including home health services or community resources, ensuring a safe transition home.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.