The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high 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
Instruct the UAP to lower the bed for safety.
This is the best action for the PN to take because it ensures the client's safety and prevents potential falls or injuries. The PN should also educate the UAP on the importance of lowering the bed when providing care to a bedfast client.
A. Assuming care of the client immediately is not necessary and may undermine the UAP's confidence and competence.
B. Remaining in the room to supervise the UAP is not appropriate and may interfere with the client's privacy and dignity.
D. Determining if the UAP would like assistance is not a priority and may not address the safety issue.
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Correct Answer is D
Explanation
Observe the UAP's technique and communication skills during the bath.
The PN should directly observe the UAP's performance and provide feedback and guidance as needed. This can help ensure that the UAP follows the standards of care and respects the client's dignity and preferences.
The other options are not correct because:
- Asking another UAP to help the orientee may not be appropriate or necessary, as it may interfere with the orientation process and create confusion or conflict.
- Verifying with the client that the bath was complete and thorough may not be sufficient or reliable, as the client may not be able to assess the quality of care or may not want to complain.
- Inspecting the client's skin near the end of the bathing procedure may not be timely or comprehensive, as it may miss some aspects of care or some problems that occurred during the bath.
Correct Answer is C
Explanation
Correct Answer: C. Measure the next voiding, then palpate the client's bladder.
Choice A rationale:
Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.
Choice B rationale:
Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.
Choice C rationale:
Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.
Choice D rationale:
Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.
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