A nurse and an assistive personnel (AP) are caring for a client. The client tells the nurse. "I noticed the assistive personnel does not wash their hands when leaving my room." Which of the following actions should the nurse take first?

Ask the AP to demonstrate proper hand hygiene techniques.

Provide clear instructions to the AP for performing hand hygiene.

Speak to the AP about the client's concern regarding hand hygiene.

Demonstrate proper hand hygiene techniques for the AP.

Answer and Explanation

The Correct Answer is C

Rationale:

A. This is incorrect as the first action. While assessing competence is useful, the immediate issue is a reported breach in infection control. The nurse must first address the specific concern and determine whether the behavior is occurring before moving to education or skills validation.

B. This is incorrect as the first action. Direct instruction may be needed, but it should come after the nurse addresses the concern and assesses the situation. Jumping immediately to instruction assumes noncompliance or lack of knowledge without confirmation.

C. This is correct. The nurse’s first priority is to address the concern directly with the assistive personnel in a professional and timely manner. This allows the nurse to clarify what is happening, assess whether hand hygiene is being performed correctly, and address any breach in infection control practice immediately to protect patient safety.

D. This is incorrect as the first action. Demonstration is an educational intervention that should occur after assessing the situation and discussing the concern with the AP. It is not the initial step in addressing a reported safety issue.

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Correct Answer is D

Explanation

Rationale:

A. An incident report should be completed when a medication error or safety event is confirmed, but it is not placed in the client’s medical record. It is a confidential quality improvement document. Additionally, the nurse must first verify whether an error has actually occurred before initiating formal reporting.

B. While contacting the charge nurse may eventually be necessary, the nurse must first verify the actual order. Acting without checking the primary source (the medication order) may lead to unnecessary escalation or misinformation.

C. The nurse should not engage in disciplinary actions. Reporting staff performance issues is not the responsibility of the bedside nurse during client care, and it violates proper chain-of-command and just culture principles.

D. The priority nursing action is to assess and verify the discrepancy by comparing the actual IV infusion with the written provider order in the medication record. This ensures accuracy and determines whether a true error exists before taking further action.

A. A client who has a hip fracture and a new onset of tachypnea B. A client who has epidural analgesia and weakness in the lower extremities C. A client who has diabetes mellitus and an HbA1c of 7.2% (less than 7%) D. A client who has sinus arrhythmia and is receiving cardiac monitoring

Correct Answer is A

Explanation

Rationale:
A. This is the correct answer because new-onset tachypnea in a client with a hip fracture is a potential sign of a life-threatening complication, especially pulmonary embolism (PE) or fat embolism syndrome, both of which are common after long-bone fractures. Tachypnea is often one of the earliest signs of impaired oxygenation. Because this represents an acute change in respiratory status, the nurse should assess this client first following the ABC (Airway, Breathing, Circulation) priority framework.

B. Lower extremity weakness is an expected effect of epidural anesthesia due to motor nerve blockade. While it should be monitored for complications (such as excessive spread of anesthesia or hematoma), it is not as immediately life-threatening as acute respiratory compromise.

C. An HbA1c of 7.2% indicates slightly above target glycemic control for many clients but is a chronic finding. It does not require immediate intervention or urgent assessment.

D. Sinus arrhythmia is often a normal physiologic variation, especially related to respiration. If the client is stable and already on cardiac monitoring, this finding is expected and not urgent compared with acute respiratory changes.

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A nurse and an assistive personnel (AP) are caring for a client. The client tells the nurse. "I noticed the assistive personnel does not wash their hands when leaving my room." Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

Correct Answer is A

Explanation

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