A charge nurse witnesses assistive personnel failing to follow facility protocol when discarding contaminated lines. 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.   While alerting the infection control department is important, directly addressing the issue with the involved personnel should be the initial action.
b.   Discussing the issue with the assistive personnel (AP) allows for immediate clarification of the protocol and provides an opportunity to correct the behavior.
c.   Reinforcing facility protocols at a staff meeting may be necessary but should not be the first step when immediate action is required.
d.   Notifying the unit manager is important, but addressing the issue with the AP directly is the first step in resolving the situation and preventing future occurrences.

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Correct Answer is D

Explanation

a. Continuing both medications may exacerbate the somnolence and difficulty arousing experienced by the client. It's essential to address the adverse effects promptly.
b. NSAIDs are not typically the first choice for severe pain management in terminal illness, especially when opioids are already prescribed. Moreover, replacing the opioid with an NSAID may not adequately address the pain.
c. Administering the benzodiazepine alongside the opioid may further potentiate the sedative effects and worsen the client's condition.
d. This is the most appropriate action. Withholding the benzodiazepine can help mitigate the sedation while continuing the opioid ensures ongoing pain relief for the client's comfort without introducing additional sedating medications.

A. Providing a 10min rest period prior to meals B. Elevating the head of the client’s bed to 30 degrees during mealtime C. Instructing the client to place her chin toward her chest when swallowing D. Withholding fluids until the end of the meal

Correct Answer is B

Explanation

a. Providing a rest period prior to meals may be appropriate for some clients, but it is not a standard technique for managing dysphagia during mealtime.
b. Elevating the head of the client’s bed to 30 degrees during mealtime helps prevent aspiration and facilitates swallowing in clients with dysphagia.
c. Instructing the client to place her chin toward her chest when swallowing is not recommended and may increase the risk of aspiration.
d. Withholding fluids until the end of the meal is not recommended for clients with dysphagia, as they may need fluids to help with swallowing and to prevent dehydration.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A hospice nurse is caring for a client who has terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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