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

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

Providing postmortem care for a client who has recently died

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

Answer and Explanation

The Correct Answer is B

A. Performing a simple dressing change on a client's foot - This action is appropriate and within the scope of practice for assistive personnel.
B. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile - Handwashing with alcohol-based hand rub is not effective against Clostridium difficile spores. Proper hand hygiene for C. difficile requires washing with soap and water. The charge nurse should intervene to correct this action and ensure proper infection control procedures are followed.
C. Providing postmortem care for a client who has recently died - Providing postmortem care is within the scope of practice for assistive personnel and is appropriate.
D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves - This action is appropriate and within the scope of practice for assistive personnel.

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Correct Answer is A

Explanation

A. Placental abruption: Placental abruption is characterized by the premature separation of the placenta from the uterine wall before delivery of the fetus. Sudden, severe abdominal pain, moderate to severe vaginal bleeding, persistent uterine contractions, and uterine rigidity are classic signs and symptoms of placental abruption. Hypotension may occur due to hemorrhage, leading to decreased perfusion to vital organs.
B. Uterine rupture: Uterine rupture involves a tear in the uterine wall, which can lead to severe abdominal pain, vaginal bleeding, and signs of shock. However, uterine rupture typically occurs during labor or delivery, particularly in women with a history of uterine surgery or trauma.
C. Placenta previa: Placenta previa is characterized by the implantation of the placenta over or near the internal cervical os. It can cause painless vaginal bleeding in the third trimester, particularly after 20 weeks of gestation. However, it is not typically associated with severe abdominal pain or uterine rigidity.
D. Amniotic fluid embolus: An amniotic fluid embolus occurs when amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, leading to a potentially life-threatening reaction. Symptoms may include sudden dyspnea, hypotension, cardiovascular collapse, and disseminated intravascular coagulation (DIC). While it can cause severe complications, the symptoms described in the scenario are more consistent with placental abruption.

A. Report sudden, persistent headaches. B. Avoid meningococcal immunizations. C. Apply cold compresses to painful areas. D. Restrict fluid intake during times of stress.

Correct Answer is A

Explanation

A. Report sudden, persistent headaches: Sudden, persistent headaches can indicate a sickle cell crisis or complications such as stroke. Prompt reporting of these symptoms allows for timely intervention and management of potential complications.
B. Avoid meningococcal immunizations: Immunizations, including meningococcal vaccines, are essential for individuals with sickle cell anemia because they are at increased risk of infections, including those caused by encapsulated bacteria like Neisseria meningitidis. Immunizations help prevent serious infections and their complications.
C. Apply cold compresses to painful areas: Cold compresses are not recommended for individuals with sickle cell anemia. Heat therapy is typically used to alleviate pain associated with vaso-occlusive crises, which are common in sickle cell disease. Heat helps relax muscles and improve blood flow to the affected area, reducing pain and promoting healing.
D. Restrict fluid intake during times of stress: Individuals with sickle cell anemia should maintain adequate hydration at all times, especially during periods of stress or illness. Dehydration can exacerbate sickling of red blood cells and increase the risk of vaso-occlusive crises. Therefore, fluid intake should be encouraged, and restrictions should be avoided unless specifically advised by a healthcare provider.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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