The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit.
Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?
The unlicensed assistive personnel tied the confused client to a chair with a sheet.
The unlicensed assistive personnel escorted the client downstairs to smoke a cigarette.
The unlicensed assistive personnel assisted the client in ambulating to the dayroom area.
The unlicensed assistive personnel bought the client a carbonated beverage from the cafeteria.
The Correct Answer is A
This scenario requires applying knowledge of safety protocols, legal standards for restraint use, and nursing delegation. Understanding that using sheets as makeshift restraints is illegal and dangerous is critical for maintaining patient safety and adhering to healthcare regulations regarding physical interventions.
Choice A rationale
Using sheets as restraints is a violation of safety standards and patient rights. Restraints require a specific medical order and must be manufactured devices. Improper tying can cause skin breakdown, strangulation, or impaired circulation in confused patients.
Choice B rationale
While smoking is generally discouraged in healthcare facilities, escorting a stable patient outdoors does not constitute an immediate safety emergency compared to illegal restraint. It requires a policy review rather than an emergency clinical intervention by the supervisor.
Choice C rationale
Assisting with ambulation is a standard task for unlicensed personnel. In a rehabilitation unit, promoting mobility is a key goal. This action is appropriate unless the patient is specifically designated as bedrest or requires a therapist.
Choice D rationale
Providing a beverage is generally within the scope of unlicensed staff unless the patient is NPO or on a restricted diet. While carbonation may not be ideal, it does not pose an immediate physical threat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Understanding skin grafting techniques is essential for postoperative burn care. Knowledge of autograft processing, specifically meshing, is required to explain how small donor skin samples are expanded to cover large wound areas while allowing for fluid drainage during healing.
Choice A rationale
While edema occurs during burn healing, the lattice pattern is a mechanical result of graft preparation rather than tissue stretching from fluid seepage. Tissue expansion occurs naturally but does not create a systematic, geometric mesh-like appearance.
Choice B rationale
Bulky dressings protect the graft site and maintain moist environments but do not cause permanent indentations in the skin. The lattice structure is a deliberate surgical modification of the donor tissue before it is applied.
Choice C rationale
Allografts are temporary covers from donors, but the lattice appearance is not caused by freezing. Meshing can be done on various graft types, but it is a physical process, not a byproduct of cryopreservation techniques.
Choice D rationale
Meshing an autograft involves cutting the skin in a geometric pattern to allow expansion. This allows a donor site to cover a larger recipient area and provides openings for exudate to escape, preventing graft displacement by fluid.
Correct Answer is A
Explanation
Acute neurological deficits following a stroke increase the risk of secondary complications. Knowledge of cranial nerve involvement and protective reflexes is vital. The nurse must prioritize airway and respiratory safety within the critical 24 hour post ischemic event window.
Choice A rationale
Right sided weakness often includes the facial and pharyngeal muscles, impairing the gag reflex and swallowing. This increases the risk of food or secretions entering the lungs, leading to pneumonia or acute respiratory distress during recovery.
Choice B rationale
While urinary retention can occur after a stroke due to neurogenic bladder or immobility, it is not an immediate life threat. It requires monitoring and management but takes lower priority than ensuring the client maintains a patent airway.
Choice C rationale
Contractures are a long term complication of immobility and muscle spasticity following a stroke. While range of motion exercises are important for rehabilitation, they are not a priority during the first 24 hours of acute stabilization.
Choice D rationale
Depression is a common psychological consequence of the lifestyle changes and deficits caused by a stroke. However, psychological assessment occurs later in the care plan after the client is physiologically stable and out of danger.
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