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A nurse manager along with members of the nurse practice committee are conducting a skills day for assistive personnel in the medical surgical unit to validate competency.

Fire Safety

Objectives:

All Staff will:

Know the location of exits, alarms, fire extinguishers, and oxygen turnoff valves.

Make sure equipment does not block fire doors.

Know the evacuation plan for the unit and the facility.

Enact RACE sequence for fire response.

Remove

Alarm

Confine

Extinguish/Evacuate

Fall Safety

Infection Control

Objectives

The staff will:

Perform proper hand hygiene.

Properly put on and remove personal protective equipment.

Gloves

Gowns

Masks

Properly disinfect patient care equipment

Review levels of precaution (standard, airborne, droplet, contact)

Which skills demonstrated by assistive personnel require immediate follow-up. Select the "3" findings that require immediate follow-up.

AP 1-Quickly pulls fire alarm, then proceeds to remove the client from room. AP 3-Raised bedrails of the bed for client who was reported not alert or oriented, and was sleeping.

AP 2-Verifies with nurse the order in which protective equipment should be removed.

AP 7- While disinfecting portable vital sign monitor wore gloves and washed hand prior to leaving room.

AP 6 - During simulation, which included assisting client into bed, there was no observed handwashing.

AP 5-Following simulation, was unable to identify the locations of alarms on medical surgical unit.

AP 4-Successfully completed skills of simulation including emptying the client's trash can

Answer and Explanation

Correct Answer : A,D,E

A. While pulling the fire alarm is correct, removing the client from the room without following the full RACE sequence (Remove, Alarm, Confine, Extinguish/Evacuate) is incorrect. The immediate safety measures should include ensuring that the alarm is activated before evacuation and confining the fire if possible.

B. Verifying the order of protective equipment removal with the nurse shows a good practice and adherence to proper infection control procedures.

C. Washing hands prior to leaving the room after disinfecting equipment indicates proper infection control practice.

D. Handwashing is a crucial aspect of infection control. Failure to perform hand hygiene during or after patient care increases the risk of infection transmission. Immediate follow-up is needed to ensure that proper hand hygiene practices are adhered to.

E. Knowing the locations of alarms is vital for effective fire safety. Inability to identify these locations indicates a significant gap in preparedness for emergencies. Immediate follow-up is necessary to ensure that staff are familiar with fire safety procedures and equipment locations.

F. Successfully completing the skills in simulation, including emptying the client's trash can, shows adherence to task requirements but is not a critical issue requiring immediate follow-up compared to the other findings.

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Correct Answer is B

Explanation

Rationale:

A. Fill the bath basin with tap water that is 39° C (102.2° F) is too warm for bathing; the recommended water temperature is typically around 37°C (98.6°F) to prevent burns or discomfort.

B. Pull the curtain around the client's bed ensures privacy for the client during the bath, which is important for maintaining dignity and confidentiality.

C. Wash the client's arms and hands first is not necessarily the first step; typically, washing the face and then moving to the rest of the body is preferred.

D. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus is incorrect as it should be done from the inner canthus to the outer canthus to avoid spreading any discharge across the eye.

A. A client who has COPD and the capillary refill time on both hands is 4 seconds B. A client who has late-stage cirrhosis and whose breath has a fruity odor C. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3 D. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided

Correct Answer is D

Explanation

Rationale:

A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.

B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.

C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.

D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

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A charge nurse is observing a nurse Insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

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