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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?

A.

Providing postmortem care for a client who has recently died.

B.

Performing a simple dressing change on a client's foot.

C.

Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile.

D.

Emptying an indwelling urinary catheter bag for a client while wearing clean gloves.

Answer and Explanation

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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Related Questions

Correct Answer is A

Explanation

- A. This choice is correct because a child who has autism spectrum disorder often exhibits strict adherence to routines and rituals, and may become distressed or agitated when there are changes or disruptions to their usual patterns.

- B. This choice is incorrect because difficulty paying attention to tasks is not a specific manifestation of autism spectrum disorder, but rather a common symptom of attentiondeficit/hyperactivity disorder (ADHD). A child who has autism spectrum disorder may have difficulty focusing on tasks that are not of interest to them, but may also show intense concentration on tasks that are of interest to them.

- C. This choice is incorrect because disobedience to authority figures is not a specific manifestation of autism spectrum disorder, but rather a common behavior problem in children and adolescents. A child who has autism spectrum disorder may have difficulty understanding social cues and expectations, but may also show compliance and cooperation when given clear instructions and positive reinforcement.

- D. This choice is incorrect because excessive anxiety when separated from parents is not a specific manifestation of autism spectrum disorder, but rather a common symptom of separation anxiety disorder. A child who has autism spectrum disorder may have difficulty forming attachments and expressing emotions, but may also show affection and attachment to familiar people.

Correct Answer is D

Explanation

Take the medication 15 min before playing sports.

  • A. Clean the mouthpiece with warm water every 2 weeks. This is incorrect because the mouthpiece should be cleaned with warm water at least once a week, or more often if used frequently, to prevent bacterial growth and contamination.
  • B. Wait 10 seconds between inhalations. This is incorrect because the recommended time interval between inhalations is 1 minute, not 10 seconds, to allow adequate absorption of the medication and prevent overdose or side effects.
  • C. Take a quick inhalation when pressing the dispenser. This is incorrect because a quick inhalation can cause poor coordination of hand-mouth movement and result in less medication reaching the lungs. The nurse should instruct the child to take a slow, deep inhalation when pressing the dispenser, hold their breath for 10 seconds, and exhale slowly.
  • D. Take the medication 15 min before playing sports. This is correct because albuterol is a short-acting bronchodilator that can prevent exercise-induced bronchospasm. The nurse should teach the child to take the medication before engaging in physical activity that can trigger asthma symptoms, such as sports, cold weather, or allergens.

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