A charge nurse is observing an assistive personnel perform delegated tasks.
Which of the following actions by the AP requires the charge nurse to intervene?

Initiate transmission-based precautions.

Rationale:

1. B- Encouraging oral fluids is an important intervention for a child who has a fever, as it helps prevent dehydration and electrolyte imbalance. However, it is not the priority intervention, as it does not address the risk of infection transmission to other clients or staff.
2. A - Applying topical calamine lotion may help soothe the itching and discomfort caused by the vesicles, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
3. C - Administering acetaminophen as an antipyretic may help reduce the fever and provide symptomatic relief for the child, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
4. D - Initiating transmission-based precautions is the priority intervention, as it protects other clients and staff from exposure to the infectious agent that causes the vesicles and fever. The nurse should wear gloves, gown, mask, and eye protection when caring for the child, and place them in a private room or cohort them with other clients who have similar symptoms.

Explore the client's reasons for refusing the treatment.

• A. Documenting the client's refusal in the medical record is an important action, but not the first one. The nurse should first try to understand the client's perspective and address any concerns or misconceptions they might have about the blood transfusion. This choice is incorrect.
• B. Honoring the client's decision to refuse the blood transfusion is a respectful and ethical action, but not the first one. The nurse should first attempt to educate and persuade the client about the benefits and risks of the treatment, and respect their autonomy only after ensuring that they have made an informed decision. This choice is incorrect.
• C. Exploring the client's reasons for refusing the treatment is the first action that the nurse should take. The nurse should use effective communication skills to elicit the client's beliefs, values, fears, and preferences regarding the blood transfusion, and provide factual and evidencebased information to address any knowledge gaps or misconceptions. The nurse should also assess the client's decision-making capacity and determine if they are competent to refuse the treatment. This choice is correct.
• D. Discussing the client's refusal with the provider is an appropriate action, but not the first one. The nurse should first try to resolve the issue with the client directly, and involve the provider only if they are unable to do so or if there are legal or ethical implications that require further consultation. This choice is incorrect.