A charge nurse witnesses an assistive personnel failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first?

Alert the infection control department

Discuss the issue with the AP

Reinforce facility protocols at the next staff meeting

Notify the unit manager about the incident

Answer and Explanation

The Correct Answer is B

a. Alert the infection control department:

While the infection control department plays a role in ensuring proper infection prevention practices, directly alerting them may not be the most immediate action to take. The charge nurse should first address the issue internally before escalating it to other departments.

b. Discuss the issue with the AP:

This is the most appropriate initial action to take. Speaking directly with the assistive personnel allows the charge nurse to clarify the correct protocol, provide education or retraining if necessary, and address any misunderstandings or lapses in adherence to facility policies.

c. Reinforce facility protocols at the next staff meeting:

While reinforcing facility protocols is important, waiting until the next staff meeting may not address the immediate concern of the observed failure to follow protocol. Direct communication with the individual involved is more effective for addressing the specific incident in a timely manner.

d. Notify the unit manager about the incident:

Notifying the unit manager about the incident may be necessary if the issue persists or if further action is required beyond the initial discussion with the assistive personnel. However, it may not be the first step to take when addressing an isolated incident.

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Correct Answer is A

Explanation

a. A client who is scheduled for an endoscopy later today and requires an enema:

Administering an enema involves basic nursing care, which falls within the scope of practice of an LPN. LPNs are trained to perform such tasks under the supervision of a registered nurse (RN).

b. A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care:

Developing an initial plan of care involves comprehensive assessment, critical thinking, and the ability to formulate nursing diagnoses and interventions. This task typically falls within the scope of practice of the RN, who has advanced education and training in care planning and coordination.

c. A client who had a myocardial infarction and will be transferring to the unit from the CCU:

Transferring a client from one unit to another may involve coordinating care, ensuring continuity of care, and communicating with other members of the healthcare team. This task may be more appropriate for an RN, who has the knowledge and skills to manage such transitions safely and effectively.

d. A newly admitted client who has diabetes mellitus and requires initial teaching on self-administration of insulin:

Providing client education, especially on self-care management such as insulin administration, requires knowledge of disease processes, medication administration, and patient teaching techniques. This task is typically within the scope of practice of the RN, who can assess the client's learning needs, provide tailored education, and evaluate the client's understanding and competency.

A. Prepare to administer antibiotics to the client B. Wear an N95 respirator mask while caring for the client C. Plan to administer an antiviral medication to the client D. Place a surgical mask on the client during transfer to the unit

Correct Answer is A

Explanation

a. Prepare to administer antibiotics to the client.

This is the correct action. Cutaneous anthrax is typically treated with antibiotics such as ciprofloxacin, doxycycline, or amoxicillin. Administering antibiotics promptly is essential to prevent the progression of anthrax infection.

b. Wear an N95 respirator mask while caring for the client.

While respiratory protection is important in certain situations, such as when caring for clients with respiratory infections, cutaneous anthrax is not transmitted through respiratory droplets. Therefore, wearing an N95 respirator mask is not necessary when caring for a client with cutaneous anthrax.

c. Plan to administer an antiviral medication to the client.

Anthrax is caused by a bacterium, not a virus, so antiviral medications would not be effective in treating anthrax infection. Antibiotics are the mainstay of treatment for anthrax.

d. Place a surgical mask on the client during transfer to the unit.

Cutaneous anthrax does not spread from person to person through respiratory droplets, so placing a surgical mask on the client during transfer is not necessary for preventing transmission of the disease.

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