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 B
Explanation
Choice A rationale:
Asking another nurse about administering adult dosages to children may provide some insights, but it is not a reliable or definitive source of information. The PN should directly communicate with the healthcare provider who wrote the prescription to ensure accuracy and safety.
Choice B rationale:
Call the healthcare provider and clarify the prescription.
Choice C rationale:
While requesting verification from the charge nurse is reasonable, the charge nurse may not have the authority to change or clarify the prescription. The most appropriate action is to directly contact the healthcare provider responsible for the child's care.
Choice D rationale:
Telling the pharmacy to send an accurate child's dosage assumes that the pharmacy made an error, which may not be the case. The PN should confirm the prescription with the healthcare provider to avoid potential mistakes or misunderstandings.
Correct Answer is C
Explanation
This is the best action for the PN to take because it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.
A. Documenting the client's loss of memory in the record is not enough and does not address the client's needs.
B. Notifying the family of the change in the client's condition is not a priority and may not be necessary if the confusion is temporary or reversible.
D. Encouraging the client to rest during the day is not appropriate and may worsen the confusion or disrupt the sleep-wake cycle.
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