A night shift nurse works and cares for several clients at risk for falls.
Which of the following actions should the nurse take?

 

Choice A rationale:

This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.

Choice B rationale:

This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.

Choice C rationale:

Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.

Choice D rationale:

Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .

The correct answer is Choice D. Speak with the AP before leaving the shift about the appropriate protocol.

Choice A rationale: Giving the AP the appropriate PPE is not the best action for the nurse to take. While this might prevent the AP from spreading the infection to other clients or themselves, it does not address the root cause of the problem, which is the AP’s lack of knowledge or compliance with the infection control policies. The nurse should educate the AP about the importance of wearing PPE and the consequences of not doing so. Giving the AP the appropriate PPE might also imply that the nurse condones the AP’s behavior, which could undermine the nurse’s authority and credibility.

Choice B rationale: Notifying the charge nurse about the AP’s lack of PPE is not the best action for the nurse to take. While this might alert the charge nurse to the issue and prompt corrective action, it does not demonstrate the nurse’s leadership and communication skills. The nurse should first attempt to resolve the issue directly with the AP, as this shows respect and professionalism. Notifying the charge nurse might also create a sense of distrust and resentment between the nurse and the AP, which could affect their working relationship and teamwork.

Choice C rationale: Volunteering to provide an in-service about infection control is not the best action for the nurse to take. While this might be a helpful and proactive way to educate the staff about the infection control policies and procedures, it does not address the immediate issue of the AP’s lack of PPE. The nurse should first speak with the AP and ensure that they understand and follow the contact precautions for the client. Volunteering to provide an in-service might also be seen as overstepping the nurse’s role and scope of practice, as this is usually the responsibility of the infection control nurse or the staff development coordinator.

Choice D rationale: Speaking with the AP before leaving the shift about the appropriate protocol is the best action for the nurse to take. This shows that the nurse is concerned about the AP’s safety and the client’s well-being, as well as the infection control standards. The nurse should explain to the AP why they need to wear PPE when entering the room of a client who is under contact precautions, and what are the risks of not doing so. The nurse should also provide the AP with feedback and reinforcement, and document the incident and the intervention. Speaking with the AP before leaving the shift also ensures that the issue is addressed in a timely and respectful manner, and that the nurse and the AP have a clear and consistent understanding of the expectations and the outcomes.