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 C

Explanation

A. Provide the client with a low-protein diet: Clients with severe preeclampsia may require dietary modifications, but a low-protein diet is not typically indicated. Instead, they may need a balanced diet with adequate protein intake to support maternal and fetal health.
B. Ambulate the client every 4 hr: Ambulation may not be suitable for a client with severe preeclampsia due to the risk of seizures and other complications associated with the condition. Bed rest or limited activity is often recommended to reduce the risk of adverse outcomes.
C. Ensure that the side rails are up on the client's bed: This action is crucial for the safety of the client with severe preeclampsia, as they are at risk of seizures, which can lead to injury from falls. Keeping the side rails up helps prevent falls and ensures the client's safety during periods of altered consciousness.
D. Check the fetal heart rate twice daily: Monitoring the fetal heart rate is essential in managing severe preeclampsia to assess fetal well-being and detect signs of fetal distress. However, the frequency of monitoring may vary depending on the severity of the condition and the healthcare provider's orders. More frequent monitoring may be necessary in some cases.

A. "A health care surrogate must be a family member." B. "The client can resume control of health care after a temporary loss of competency." C. "The provider will choose a client's health care surrogate." D. "The provider can go against the client's wishes regarding advance directives."

Correct Answer is B

Explanation

A. "A health care surrogate must be a family member.": This statement is incorrect. A health care surrogate, also known as a health care proxy or agent, does not necessarily have to be a family member. It can be any individual chosen by the client to make health care decisions on their behalf if they become unable to do so.
B. "The client can resume control of health care after a temporary loss of competency.": This statement demonstrates an understanding of advance directives. Advance directives allow individuals to maintain control over their health care decisions by specifying their preferences for treatment or appointing a surrogate decision-maker. If a client experiences a temporary loss of competency, they can regain control of their health care decisions once competency is restored.
C. "The provider will choose a client's health care surrogate.": This statement is incorrect. It is the responsibility of the client to choose their health care surrogate. While healthcare providers may provide guidance and information about advance directives, they do not choose the surrogate for the client.
D. "The provider can go against the client's wishes regarding advance directives.": This statement is incorrect. Advance directives are legally binding documents that express a client's wishes regarding medical treatment. Healthcare providers are generally obligated to follow the directives outlined in these documents, and they cannot go against the client's wishes unless certain legal exceptions apply, such as emergency situations where immediate action is required to preserve life.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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