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 C
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 not sufficient. Alcohol is not effective against C. Difficile spores.
Choice D rationale:
Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Sodium level of 142 mEq/L is within the normal range (135-145 mEq/L) for adults. However, normal ranges for children might vary slightly, but 142 mEq/L is not indicative of dehydration on its own.
Choice B rationale:
Respiratory rate of 22/min is within the normal range for a 3-year-old child (20-30 breaths/min) This rate alone does not provide evidence of dehydration.
Choice C rationale:
Potassium level of 3.9 mEq/L is within the normal range (3.5-5.1 mEq/L) for children. Like sodium, normal ranges for potassium may differ slightly in pediatric patients, but 3.9 mEq/L is not alarming on its own.
Choice D rationale:
Heart rate of 148/min is elevated for a 3-year-old child. Tachycardia is a common sign of dehydration in pediatric patients. This increased heart rate indicates the body's compensatory mechanism to maintain cardiac output in response to decreased blood volume, a typical consequence of dehydration.
Correct Answer is B
Explanation
Allow for frequent rest periods throughout the day.
- A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
- B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
- C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain. - D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.
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