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

Answer and Explanation

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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Correct Answer is ["C"]

Explanation

a. Store opened bottles of normal saline in a refrigerator for up to 48 hours:

Incorrect. Once opened, bottles of normal saline should generally be used within a short time frame (typically 24 hours) and should not be stored for extended periods to prevent contamination. This practice could lead to infection risks and is not recommended as a cost-containment measure.

b. Wait to dispose of sharps containers until they are completely full:

Incorrect. Overfilling sharps containers increases the risk of needle-stick injuries and potential exposure to bloodborne pathogens. Sharps containers should be disposed of when they are about three-quarters full to maintain safety.

c. Use clean gloves rather than sterile gloves for colostomy care:

Correct. For colostomy care, clean gloves are generally sufficient as it is a clean procedure, not a sterile one. Using clean gloves instead of sterile gloves reduces costs without compromising patient safety.

d. Return unused supplies from the bedside to the unit’s supply stock:

Incorrect. Returning unused supplies to the general supply stock can pose a risk of cross-contamination and infection. Once supplies have been brought to a patient's bedside, they are considered contaminated and should not be returned to the supply area.

A. Institute rounds every 2 hr during the day to offer toileting B. Apply vest restraints on residents who are confused C. Accompany residents older than 85 years of age during ambulation D. Keep the four side rails up on beds at night

Correct Answer is A

Explanation

a. Institute rounds every 2 hr. during the day to offer toileting:

This intervention is appropriate as it helps address the need for toileting assistance, which can reduce the risk of falls associated with residents attempting to ambulate to the bathroom independently. Regular toileting rounds can help prevent falls related to toileting urgency or difficulty.

b. Keep four side rails up on the beds at night:

Keeping all four side rails up on the beds can increase the risk of entrapment and may not be necessary for all residents. Using bed rails should be individualized based on each resident's risk assessment and should follow facility policies and guidelines to prevent entrapment and ensure resident safety.

c. Apply vest restraints on the residents who are confused:

Using restraints, such as vest restraints, should be avoided whenever possible due to the increased risk of physical and psychological harm to residents. Restraints do not address the underlying causes of falls and can contribute to agitation, loss of mobility, and pressure injuries.

d. Accompany residents older than 85 years of age during ambulation:

This intervention is appropriate, especially for residents who are at increased risk of falls, such as those over 85 years of age. Accompanying residents during ambulation allows for assistance and support, reduces the risk of falls, and provides an opportunity for early intervention if balance or mobility issues arise.

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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?

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