A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?
Evaluate why the client was not ambulated.
Ambulate the client on behalf of the AP.
Supervise the AP performing the task.
Remind the AP of her assigned tasks.
The Correct Answer is A
Rationale:
A. Evaluate why the client was not ambulated.: The first step in addressing a missed delegated task is to assess the reason it was not completed. Understanding whether barriers were related to the AP, client condition, workload, or communication helps the nurse plan corrective action and prevents recurrence.
B. Ambulate the client on behalf of the AP.: While ensuring the client’s needs are met is important, jumping straight to performing the task bypasses assessment of the underlying issue. Immediate action may address the symptom but not the cause of the missed delegation.
C. Supervise the AP performing the task.: Supervision is appropriate for ongoing tasks but is not the first action once a task has already been missed. The nurse must first determine why the task was not completed before implementing supervision.
D. Remind the AP of her assigned tasks.: Reminding the AP without assessing why the task was missed does not address potential systemic or situational barriers. It may be necessary later but is not the initial step in problem resolution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "You should not drink through a straw for 2 weeks.": Drinking through a straw can create pressure in the middle ear, which may dislodge the tympanic membrane graft or interfere with healing after a myringotomy. Avoiding straws is an important precaution to protect the surgical site and promote proper recovery.
B. "You should expect excessive ear drainage for about 48 hours": Some drainage may occur, but excessive drainage is not expected and could indicate infection or complications. Clients should be instructed to report any abnormal or persistent drainage to the provider rather than expecting it as normal.
C. "You can wash your hair 3 days after the procedure.": Hair washing is typically delayed until the provider confirms it is safe, usually after avoiding water in the ear for a few days. Premature washing could allow water to enter the middle ear, increasing the risk of infection.
D. "You should blow your nose with your mouth closed": Blowing the nose increases pressure in the middle ear and can compromise the healing of the tympanic membrane. Clients should be taught to avoid nose-blowing entirely or do so gently with the mouth open if necessary.
Correct Answer is ["2.5"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 20 mg
Available Concentration: 40 mg/5 mL
- Calculate the volume to administer
Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration
Volume to administer = (20 ÷ 40) × 5
Volume to administer = 0.5 × 5
Volume to administer = 2.5 mL
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