An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client who is prescribed bedrest with bedside commode use. The UAP reports to the nurse that the client's obesity makes it difficult to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?

Advise the client to maintain bedrest to ensure safety.

Instruct the UAP that all clients deserve equal care.

Determine the client's level of mobility and need for assistance.

Assign another UAP to care for the client.

Answer and Explanation

The Correct Answer is C

Choice A reason: Advising the client to maintain bedrest may not be practical or beneficial for the client's overall health and does not address the UAP's concern about safe transfer.

Choice B reason: While it is true that all clients deserve equal care, this statement does not provide a solution to the UAP's concern about safely assisting the client.

Choice C reason: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.

Choice D reason: Assigning another UAP may be necessary if the current UAP is unable to assist safely, but it is not the first step. The nurse should first assess the situation before making staffing changes.

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Correct Answer is A,B,C,D,E

Explanation

Choice A reason: The first step is to document the concerns for an accurate record and report them to the charge nurse to address the issue internally within the unit.

Choice B reason: If the issue is not resolved at the unit level, the next step is to discuss the matter with the physician directly as a group, which can lead to a resolution without escalating the situation.

Choice C reason: Should the problem persist, submitting a written report to the Director of Nursing is appropriate to involve higher management and seek further action.

Choice D reason: If the issue remains unresolved after involving the Director of Nursing, contacting the hospital's Chief of Medical Services is the next step to escalate the matter within the hospital's administrative structure.

Choice E reason: As a last resort, if all internal avenues have been exhausted and the problem persists, filing a formal complaint with the state medical board is necessary to address potential violations of professional conduct.

A. Place the child on a continuous cardiopulmonary monitor B. Check pedal pulses every 4 hours C. Point of care blood glucose D. Admit to the pediatric floor for observation E. Vital signs every 4 hours F. Check dressing every 15 minutes for 1 hour and then every hour for 24 hours G. NPO

Correct Answer is ["C","G"]

Explanation

Choice A reason: Placing the child on a continuous cardiopulmonary monitor is a standard post-operative order for monitoring the child’s heart and lung function after cardiac catheterization.
Choice B reason: Checking pedal pulses every 4 hours is important to ensure that there is adequate blood flow to the extremities, which can be compromised after cardiac procedures.
Choice C reason: Point of care blood glucose testing every 6 hours may not be necessary unless the child has a history of diabetes or there was a specific concern during the procedure. This order should be clarified with the physician.
Choice D reason: Admitting the child to the pediatric floor for observation is a standard procedure to monitor for any complications following cardiac catheterization.
Choice E reason: Monitoring vital signs every 4 hours is a typical post-operative order to ensure the child’s stability after the procedure.
Choice F reason: Checking the dressing every 15 minutes for 1 hour and then every hour for 24 hours is a standard order to monitor for bleeding or other complications at the catheterization site.
Choice G reason: The order for NPO status might need to be questioned depending on the time expected before the child can eat or drink again, especially considering the child’s age and the need for hydration and nutrition.
Choice H reason: Administering Lactated Ringers IV at 66 mL/hr while NPO is a standard order to maintain hydration while the child cannot take anything by mouth.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A,B,C,D,E

Explanation

Patient Data Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

Correct Answer is ["C","G"]

Explanation

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