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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:
a. Administering an enema for a scheduled endoscopy is within the scope of practice for an LPN. It involves a task that is repetitive, stable, and does not require critical thinking.
b. Developing an initial plan of care for a client with sickle cell anemia involves critical thinking and assessment, which are within the scope of practice for an RN.
c. A client transferring from the CCU after a myocardial infarction requires close monitoring and assessment, which are typically within the scope of practice for an RN.
d. Teaching a newly admitted client about self-administration of insulin involves education, assessment, and critical thinking, which are typically within the scope of practice for an RN.

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 the visitor viewed a client’s protected health information D. Inform the visitor that client records are confidential

Correct Answer is A

Explanation

A. Closing the documentation program on the computer is the most immediate action to prevent further unauthorized access to protected health information (PHI). It directly addresses the breach of confidentiality and limits potential damage.

B. While it is important to identify the staff member responsible for leaving the program open, this does not immediately address the current breach of confidentiality. This action would be a subsequent step after securing the PHI.

C. Notifying the charge nurse is an important step in the process of addressing the breach. However, it is not the first action to take as it does not prevent further exposure of the PHI.

D. Informing the visitor about the confidentiality of client records is necessary, but it is not the first action to take. The priority is to secure the PHI before addressing the visitor's behavior.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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