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?

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

Help the AP assist the client with the transfer.

Refer the AP to the facility procedure manual.

Demonstrate the proper client transfer technique for the AP.

Answer and Explanation

The Correct Answer is B

A.   Instruct the AP to request assistance when unsure about a task: While this is an important instruction, the immediate priority is ensuring the safety of the client during the transfer.
B.   Help the AP assist the client with the transfer: This is the correct answer. The nurse should intervene immediately to ensure the safety of the client during the transfer. Providing assistance to the AP in safely transferring the client is the most appropriate action to take first.
C.   Refer the AP to the facility procedure manual: While facility procedures are important, referring to the manual may not address the immediate need to correct the incorrect transfer and ensure client safety.
D.   Demonstrate the proper client transfer technique for the AP: While education and demonstration of correct techniques are important, the immediate priority is to intervene and ensure the safety of the client during the transfer.

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Correct Answer is ["A","E"]

Explanation

A. This is a breach of confidentiality because discussing a client's condition in a public area where unauthorized individuals can overhear is inappropriate. Confidential information should only be shared in private settings where privacy can be ensured.
B. Logging out of the computer is not a breach of confidentiality; it is a security measure to protect client information.
C. Reviewing an electronic list of clients admitted to the unit is part of routine nursing duties and does not constitute a breach of confidentiality as long as the information is not disclosed to unauthorized individuals.
D. Faxing client data to a referred provider is a part of continuity of care and is not a breach of confidentiality if done following proper protocols to ensure the information is received by the intended recipient.
E. Informing a friend of the client about their condition without consent is a breach of confidentiality. Information about a client's condition should only be shared with individuals who are authorized to receive it, typically those involved in the client's care or those the client has
given permission to be informed.

A. Reposition the client frequently. B. Instruct the client to use the incentive spirometer. C. Increase the amount of time the client spends out of bed each day. D. Ensure the client consumes an adequate amount of fluids.

Correct Answer is B

Explanation

A. Reposition the client frequently: While repositioning is important for preventing pressure ulcers and maintaining comfort, it may not be the priority immediately postoperatively compared to other interventions.
B. Instruct the client to use the incentive spirometer: This is the correct answer. Incentive spirometry helps prevent atelectasis and respiratory complications postoperatively, making it a priority intervention to include in the plan of care.
C. Increase the amount of time the client spends out of bed each day: Early ambulation is important for preventing complications such as deep vein thrombosis and pneumonia, but it may not be the priority immediately postoperatively depending on the client's condition and surgical procedure.
D. Ensure the client consumes an adequate amount of fluids: While hydration is important for postoperative recovery, ensuring adequate fluid intake may not be the priority compared to interventions aimed at preventing respiratory complications such as atelectasis.

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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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Correct Answer is ["A","E"]

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Correct Answer is B

Explanation

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