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 D

Explanation

a. Review the chart for nonrestraint alternatives for agitation:

This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.

b. Inform the unit manager:

Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.

c. Speak with the AP about the incident:

Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.

d. Remove the restraints from the client’s wrist:

In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.

A. Close the documentation program on the computer B. Find out which staff member left the documentation program on the screen C. Tell the charge nurse that a visitor viewed a client’s protected health information D. Inform the visitor that client records are confidential

Correct Answer is A

Explanation

a. Close the documentation program on the computer:

This action is appropriate as it immediately stops unauthorized access to the client's medical information and prevents further viewing of protected health information (PHI).

b. Find out which staff member left the documentation program on the screen:

While it's important to identify any staff member who may have left the documentation program open, addressing this issue should not be the first priority. The immediate concern is stopping the unauthorized access to the client's information and ensuring that the visitor is aware of the confidentiality breach.

c. Tell the charge nurse that the visitor viewed a client’s protected health information:

Notifying the charge nurse about the incident is important, but it should not be the first action taken. The priority is to address the immediate breach of confidentiality and prevent further unauthorized access to the client's information.

d. Inform the visitor that client records are confidential:

This action may be appropriate after addressing the immediate breach of confidentiality. However, it should not be the first action taken as it does not immediately stop the unauthorized access to the client's information.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse making rounds observes that an assistive personnel has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse enters the hallway and discovers a visitor looking at a client’s medical information on a computer. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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