A nurse manager observes an assistive personnel 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
Demonstrate the proper client transfer technique for the AP
Help the AP assist the client with the transfer
Refer the AP to the facility procedure manual
The Correct Answer is C
a. Help the AP assist the client with the transfer.
While it is important to instruct the AP to seek assistance when unsure, this does not immediately address the safety of the client during the current incorrect transfer.
b. Demonstrate the proper client transfer technique to the AP.
Demonstrating the proper technique is an important step, but it should come after ensuring the immediate safety of the client. This can be done once the client is safely transferred.
c. Instruct the AP to request assistance when unsure about a task.
Correct. The nurse's first priority should be the safety of the client. By immediately assisting the AP with the transfer, the nurse ensures the client's safety and prevents potential injury.
d. Refer the AP to the facility procedure manual.
Referring the AP to the procedure manual is important for future reference, but it does not address the immediate risk to the client. This action can be taken after ensuring the client's safety and demonstrating the correct technique.
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Related Questions
Correct Answer is C
Explanation
a. Educate the client about the risks of refusing the procedure:
This option suggests providing information about the potential consequences of not undergoing the gastroscopy. While educating the client about risks is essential, the immediate concern is the client's lack of understanding about the procedure itself.
b. Complete the incident report:
Filling out an incident report is typically reserved for situations where there has been an actual incident, such as a medical error or adverse event. In this case, the client's lack of understanding does not constitute an incident but rather a need for clarification.
c. Inform the provider that the client requires clarification about the procedure:
This is the correct action. It involves escalating the issue to the provider responsible for performing the gastroscopy. The provider can then address the client's concerns, answer questions, and provide additional information to ensure informed consent.
d. Answer the client’s questions concerning the procedure:
While answering the client's questions is important, it's not solely the nurse's responsibility to ensure the client understands the procedure. The provider, who will perform the gastroscopy, should be informed of the client's confusion so they can address it effectively.
Correct Answer is B
Explanation
a. Recommend the AP come back later when the record is available:
This option delays the documentation process unnecessarily and may inconvenience the AP.
It doesn't address the issue of maintaining patient confidentiality and accurate documentation.
b. Log out so the AP can log in to document the vital signs:
This is the correct choice as it ensures that each individual's documentation is attributed to the correct user.
It maintains patient confidentiality and adheres to HIPAA regulations.
It allows the AP to complete their task efficiently while preserving the integrity of the electronic record.
c. Offer to chart the vital signs for the AP:
This option involves the nurse taking over the responsibility of documenting the vital signs for the AP, which could lead to confusion and potential errors.
It's not the most appropriate solution as it may not be feasible for the nurse to document the vital signs accurately without directly measuring them.
d. Allow the AP to document the vital signs prior to logging out:
Allowing the AP to document vital signs under the nurse's login compromises the integrity of the electronic record and violates HIPAA regulations.
It's not an acceptable practice as it can lead to inaccuracies in the documentation and compromises patient confidentiality.
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