A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

Refer the AP to the facility procedure manual.

Instruct the AP to request assistance when unsure about a task.

Demonstrate the proper client transfer technique for the AP.

Help the AP assist the client with the transfer.

Answer and Explanation

The Correct Answer is D

A. Referring the AP to the facility procedure manual does not provide immediate support or correct the unsafe practice observed. It may not address the situation in real-time.

B. While instructing the AP to request assistance is important for future situations, it does not immediately rectify the incorrect technique being used at that moment.

C. While demonstrating the correct technique is valuable, the immediate priority is ensuring the client’s safety by assisting with the current transfer. A demonstration should follow after the immediate risk has been managed.

D. The first priority is client safety. If the nurse manager observes an incorrect transfer technique, the immediate response should be to intervene to prevent injury to the client or the AP. Assisting with the transfer ensures that the client is safely positioned while also providing an opportunity to correct the AP's actions in real time.

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Correct Answer is B

Explanation

A. Involving the ethics committee may be unnecessary if the client's advance directives are clear.

B. This response directly addresses the client's wishes as stated in their advance directives, reinforcing the importance of honoring their preferences regarding life-sustaining treatment.

C. Suggesting that tube feeding will make the client feel better contradicts the advance directives and does not respect the client's wishes.

D. Discussing the matter with the rest of the family may not be appropriate if the partner is the designated surrogate and the client's wishes are clearly outlined in the advance directives.

A. Assesses the client's gag reflex following an esophagogastroduodenoscopy B. Maintains the chest tube collection device below the level of the insertion site when ambulating the client C. Elevates the head of the client's bed to 30° before inserting a nasogastric tube D. Assists the client into a fetal position on his side in preparation for a lumbar puncture

Correct Answer is C

Explanation

A. Assessing the gag reflex after an esophagogastroduodenoscopy is appropriate because it ensures the client has recovered from anesthesia, reducing the risk of aspiration.

B. Keeping the chest tube collection device below the insertion site is proper technique, as it promotes drainage and prevents backflow into the chest cavity.

C. Elevating the head of the bed to 30° for nasogastric tube insertion is incorrect. The head of the bed should be elevated to 45-90° to facilitate easier insertion and reduce the risk of aspiration.

D. Assisting the client into the fetal position is the correct position for a lumbar puncture because it helps open the spaces between vertebrae, allowing easier needle insertion.

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A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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