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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Domestic violence assistance is an important topic, but it falls under secondary and tertiary prevention rather than primary disease prevention, which is the focus of this community outreach program. Primary prevention aims to prevent the disease from occurring in the first place, while domestic violence assistance addresses an existing issue.

Choice B rationale:

Blood pressure screening is valuable for early detection of hypertension, but it also falls under secondary prevention. Primary prevention focuses on preventing the onset of diseases through measures such as immunizations, health education, and lifestyle modifications.

Choice D rationale:

Outreach for support group information is essential for clients with chronic conditions or specific needs. However, it is not primarily related to preventing diseases at the population level, which is the primary goal of this community outreach program. This topic may be more relevant to secondary and tertiary prevention efforts.

A. Check femoral site for hematoma formation. B. Stimulate the client to take deep breaths. C. Evaluate the integrity of the IV insertion site. D. Assess distal lower extremity capillary refill.

Correct Answer is A

Explanation

Choice A rationale:

Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.

Choice B rationale:

Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.

Choice C rationale:

Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.

Choice D rationale:

Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.

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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?

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Correct Answer is C

Explanation

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Explanation

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