A nurse manager observes assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?
Help the AP assist the client with the transfer
Demonstrate the proper client transfer technique to the AP
Instruct the AP to request assistance when unsure about a task
Refer the AP to the facility procedure manual
The Correct Answer is A
A. Helping the assistive personnel immediately ensures the client’s safety, which is the nurse’s top priority. Incorrect transfer techniques can lead to falls or injury, so the nurse must intervene right away to prevent harm.
B. Demonstrating proper transfer technique is important for education, but it should occur after the immediate safety issue is resolved.
C. Instructing the AP to request assistance when unsure is appropriate teaching, but it does not address the immediate risk to the client during the transfer.
D. Referring the AP to the procedure manual is not a priority in an active situation where the client could be injured. Education and reference can occur later.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Keeping the ring for the client until after the surgery may not ensure its safety and could lead to loss or misplacement.
b. Placing the client's ring in the facility safe ensures its security and prevents loss or theft during the surgical procedure.
c. Taping the ring securely to the client's finger may not be comfortable or safe during surgery and could potentially lead to complications.
d. Placing the ring in the bag with the client's clothes may not ensure its security and could lead to loss or misplacement.
Correct Answer is B
Explanation
a. Providing a rest period prior to meals may be appropriate for some clients, but it is not a standard technique for managing dysphagia during mealtime.
b. Elevating the head of the client’s bed to 30 degrees during mealtime helps prevent aspiration and facilitates swallowing in clients with dysphagia.
c. Instructing the client to place her chin toward her chest when swallowing is not recommended and may increase the risk of aspiration.
d. Withholding fluids until the end of the meal is not recommended for clients with dysphagia, as they may need fluids to help with swallowing and to prevent dehydration.
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