A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

Volunteer to provide an inservice about infection control.

Speak with the AP when he exits the room about the appropriate protocol.

Provide the appropriate PPE to the AP.

Notify the charge nurse about the AP's need for training.

Answer and Explanation

The Correct Answer is C

A. Volunteer to provide an inservice about infection control. While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.

B. Speak with the AP when he exits the room about the appropriate protocol. Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.

C. Provide the appropriate PPE to the AP. This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.

D. Notify the charge nurse about the AP's need for training. Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.

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Correct Answer is C

Explanation

Choice A rationale:

Asking the patient why this medication has been ordered is not the appropriate action because patients might not have accurate medical knowledge to provide a valid explanation for the prescription. The nurse should rely on healthcare professionals for accurate information.

Choice B rationale:

Verifying with the hospital administration is not necessary in this situation. The decision to prescribe medication is made by the healthcare provider, not the hospital administration.

Choice C rationale:

Verifying with the prescribing healthcare provider is the most appropriate action. The healthcare provider has the medical knowledge and rationale for prescribing a specific medication. This ensures that the nurse administers the medication safely and in alignment with the patient's condition and treatment plan.

Choice D rationale:

Asking another nurse might not yield accurate information about the rationale behind the medication order. It's best to directly communicate with the healthcare provider responsible for the patient's care.

A. Explain to the client that he needs the protein in the milk and the beef. B. Allow the AP to deliver the food tray to the client. C. Replace the nonfat milk with apple juice. D. Call the dietary department and ask for a kosher tray.

Correct Answer is D

Explanation

Choice A rationale:

Explaining to the client that he needs the protein in the milk and the beef is not an appropriate action. Understanding and respecting the client's religious and dietary preferences are essential. Orthodox Jewish dietary laws, known as kashrut, prohibit the consumption of certain foods, including the mixing of meat and dairy in the same meal. This response disregards the client's faith-based dietary restrictions.

Choice B rationale:

Allowing the AP to deliver the food tray to the client is not appropriate in this situation. The nurse is responsible for ensuring that the client's dietary needs and preferences are met, especially when there are religious considerations involved. Failing to accommodate the client's dietary requirements could lead to non-compliance and potential harm.

Choice C rationale:

Replacing the nonfat milk with apple juice does not address the client's religious dietary restrictions. While the change may avoid mixing meat and dairy, it still disregards the importance of providing a kosher meal. Kosher dietary laws encompass more than just avoiding meat and dairy combinations. It is important to provide a fully compliant kosher meal.

Choice D rationale:

Calling the dietary department and asking for a kosher tray is the appropriate action. A kosher diet adheres to specific rules and regulations, including the separation of meat and dairy products. To respect the client's faith and dietary needs, the nurse should ensure that the food provided aligns with kosher guidelines. This choice demonstrates cultural sensitivity and ensures the client's well-being.

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A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

Nursing Test Bank

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