The practical nurse (PN) observes an unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in the high fowlers position. Which action should the PN take?
Assume care of the client immediately.
Remain in the room to supervise the UAP.
Instruct the UAP to lower the bed for safety.
Determine if the UAP would like assistance.
The Correct Answer is C
The correct answer is choice C: Instruct the UAP to lower the bed for safety.
Choice C rationale: When bathing a bedfast client, the bed should be in a flat or low position to reduce the risk of the client sliding down, falling, or experiencing discomfort or injury. By instructing the UAP to lower the bed, the PN ensures client safety during the bathing process.
Choice A rationale: Assuming care of the client immediately might be unnecessary. The PN should first address the safety concern and then determine if additional intervention is needed.
Choice B rationale: While supervising the UAP may be appropriate in certain situations, the priority in this case is to address the immediate safety concern by instructing the UAP to lower the bed. The PN can then decide if supervision or assistance is required.
Choice D rationale: Determining if the UAP would like assistance is considerate, but it is not the priority in this situation. Ensuring client safety by lowering the bed should be addressed first. The PN can then assess whether the UAP needs any help or guidance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Monitoring ETT markings between 22 and 26 cm at the teeth line is essential to ensure proper placement of the endotracheal tube (ETT). This helps confirm that the ETT is positioned correctly in the trachea.
Choice B rationale:
Checking for capillary refill is not a reliable method for verifying the placement of an ETT. It is more indicative of peripheral circulation and not related to airway management.
Choice C rationale:
Obtaining a portable chest x-ray is a crucial step to verify the exact placement of the ETT within the trachea and to rule out potential complications such as pneumothorax.
Choice D rationale:
Assessing for symmetrical chest movement is important because unequal chest rise and fall could indicate an issue with ETT placement or lung function.
Choice E rationale:
Auscultating for bilateral breath sounds is another method to confirm that the ETT is correctly positioned in the trachea and that both lungs are being ventilated adequately.
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. Suicidal ideation is not a diagnosis in itself but rather a symptom or thought process associated with various mental health conditions.
Choice B rationale:
This statement is incorrect. Suicidal ideation can occur in individuals of all age groups, not just in older adults. It is not limited to any specific age demographic.
Choice C rationale:
This statement is incorrect. Suicidal ideation does not always involve a detailed plan for self-harm. It can range from fleeting thoughts of self-harm to more detailed plans, but the severity can vary widely.
Choice D rationale:
This statement is accurate. Suicidal ideation can be a symptom of various underlying mental health conditions, including depression, anxiety disorders, bipolar disorder, and others. It involves thoughts of self-harm or suicide, which may or may not be accompanied by specific plans.
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