The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. Which action should the nurse take?
Remind the UAP to dry between the client’s toes completely.
Advise the UAP that this procedure is damaging to the skin.
Add skin cream to the basin of water while the foot is soaking.
Remove the basin of water from the client’s bed immediately.
The Correct Answer is D
Choice A: Remind the UAP to dry between the client’s toes completely is not the best action because it does not address the risk of spillage and wetness on the bed. Drying between the toes is important to prevent fungal infections, but it can be done after removing the basin.
Choice B: Advise the UAP that this procedure is damaging to the skin is not the best action because it is not accurate and may cause confusion. Soaking the foot in warm water is not harmful to the skin, unless it is too hot or too long.
Choice C: Add skin cream to the basin of water while the foot is soaking is not the best action because it does not solve the problem and may waste the cream. Skin cream should be applied after drying the foot, not mixed with water.
Choice D: Remove the basin of water from the client’s bed immediately is the best action because it prevents potential hazards such as soaking, infection, or electric shock. The nurse should ensure that the bed is dry and clean before continuing with the bath.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because waiting for notification that the system has been rebooted can delay the client's care and compromise safety. The nurse should report the problem as soon as possible and use alternative methods of documentation.
Choice B Reason: This is incorrect because identifying information as late entry in the record is a secondary action that should be done after the system is restored. The nurse should prioritize resolving the technical issue and ensuring continuity of care.
Choice C Reason: This is correct because notifying information services department of the situation is the first action that the nurse should take to alert the experts who can troubleshoot and fix the problem. The nurse should also follow the facility's policy and procedure for documenting in a downtime situation.
Choice D Reason: This is incorrect because printing electronic medical record (EMR) from backup server may not be feasible or accessible depending on the extent of the system failure. The nurse should use paper forms or charts as a temporary measure until the system is back online.
Correct Answer is D
Explanation
Choice A: "I'm sorry, but your child's medical information is none of your business." is not a good response because it is rude and disrespectful. The nurse should maintain professionalism and empathy when dealing with parents.
Choice B: "I can give you those results as soon as I get them back from the lab." is not a good response because it violates confidentiality and privacy. The nurse should not share any medical information with anyone without the client's consent.
Choice C: "The healthcare provider will share this information with you." is not a good response because it implies that the parents have a right to know their child's medical information. The nurse should not make promises or assumptions that may not be true.
Choice D: "I can only give medical information to your child because they are legally an adult." is a good response because it explains the legal status of an emancipated minor and respects their autonomy. The nurse should inform the parents that their child has the right to make their own decisions regarding their health care.
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