A nurse is observing an assistive personnel (AP) provide care to a group of clients. Which of the following actions by the AP requires intervention by the nurse?

Removing gloves before leaving an isolation room

Filling a basin with water at 40° C (104° F) when providing foot care

Instructing a client to look down at their feet when being assisted to ambulate

Applying water-soluble lubricant to the nares of a client who is receiving oxygen

Answer and Explanation

The Correct Answer is B

A. Removing gloves before leaving an isolation room is appropriate practice and helps prevent the spread of infection.
B. Filling a basin with water at 40° C (104° F) is too hot for foot care and could lead to burns or injury; water temperature for foot care should be comfortably warm, typically around 37°C (98.6°F).
C. Instructing a client to look down at their feet when being assisted to ambulate is a safety measure that can help the client maintain balance and avoid tripping.
D. Applying water-soluble lubricant to the nares of a client receiving oxygen is a standard practice to prevent dryness and does not require intervention.

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Correct Answer is D

Explanation

A. Asking each nurse for information about the problem is essential, but it should occur after addressing the immediate need for privacy.
B. Listening to the concerns of each staff nurse is important, but doing so in a private area ensures confidentiality and reduces further escalation.
C. Discussing ways to resolve the conflict is necessary, but first creating a safe and private environment is vital for open communication.
D. Moving the staff nurses to a private area is the first step to ensure they can discuss their conflict without external pressures or interruptions, which facilitates a more constructive dialogue.

A. Respect the daughter's decision to refuse the transfusion. B. Encourage the daughter to let her mother have the transfusion. C. Discuss taking guardianship of the client with the facility administration. D. Ask the provider to give consent for the transfusion.

Correct Answer is A

Explanation

A. Respecting the daughter's decision to refuse the transfusion aligns with the principles of patient autonomy and the authority granted through the durable power of attorney for health care, meaning the daughter's wishes must be followed.
B. Encouraging the daughter to allow the transfusion would undermine her role as the decision-maker and may cause unnecessary conflict, making this option inappropriate.
C. Discussing guardianship is not necessary or appropriate in this context, as the daughter has already been designated as the decision-maker, which negates the need for additional legal intervention.
D. Asking the provider to give consent for the transfusion contradicts the authority granted to the daughter, as she is the legally recognized decision-maker and has already made her choice.

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A nurse is observing an assistive personnel (AP) provide care to a group of clients. Which of the following actions by the AP requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is witnessing a conflict between two staff nurses about a client assignment. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her adult daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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