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?
Providing postmortem care for a client who has recently died.
Performing a simple dressing change on a client's foot.
Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile.
Emptying an indwelling urinary catheter bag for a client while wearing clean gloves.
The Correct Answer is D
Choice A rationale:
Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.
Choice B rationale:
Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.
Choice C rationale:
Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is a necessary infection control measure. The charge nurse does not need to intervene as long as the AP follows proper hand hygiene protocols. Using alcohol-based hand rub is effective in killing most bacteria and viruses, including C. difficile.
Choice D rationale:
Emptying an indwelling urinary catheter bag for a client while wearing clean gloves is inappropriate and requires immediate intervention by the charge nurse. It violates infection control protocols because the AP should wear disposable gloves when handling bodily fluids. Clean gloves are not sufficient for this task, as they do not provide adequate protection against the transmission of infections. The charge nurse should intervene, re-educate the AP, and ensure the correct protocol is followed to prevent the risk of infection transmission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A. Incorrect. The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).
- B. Incorrect. The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45).
- C. Correct. The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).
- D. Incorrect. The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).
Correct Answer is A
Explanation
- A. Correct. The nurse should initiate continuous cardiac monitoring because a magnesium level of 2.7 mEq/L indicates hypermagnesemia, which can cause cardiac dysrhythmias, hypotension, and bradycardia.
- B. Incorrect. The nurse should not administer potassium chloride to a client who has hypermagnesemia because it can worsen the condition by increasing the intracellular magnesium level and decreasing the serum calcium level.
- C. Incorrect. The nurse should not provide a diet rich in legumes, nuts, and green vegetables to a client who has hypermagnesemia because these foods are high in magnesium and can increase the serum magnesium level.
- D. Incorrect. The nurse should not monitor the client for tetany because tetany is a sign of hypomagnesemia, not hypermagnesemia. Hypomagnesemia can cause neuromuscular excitability, muscle spasms, and positive Chvostek's and Trousseau's signs
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