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 A

Explanation

A. Reviewing evidence-based literature is essential to understand best practices in shift reporting and can inform the development of effective interventions. This foundational step helps ensure that any proposed changes are supported by research and proven methods.
B. While organizing a task force can be beneficial, it should occur after understanding the current best practices, as the task force's efforts would be better guided with existing evidence.
C. Creating a new reporting process without first gathering information or reviewing best practices may result in ineffective or unnecessary changes.
D. Developing a strategy to alert nurses is important, but it should be based on informed decisions derived from literature and data analysis, which should come first.

A. Wear protective eyewear. B. Wear a mask when changing the dressing. C. Use dedicated equipment for this client. D. Turn on the HEPA filtration system.

Correct Answer is C

Explanation

A. Wearing protective eyewear is not typically required for dressing changes unless there is a risk of splashing or spraying of fluids.
B. A mask is not necessary for dressing changes unless there is a risk of respiratory droplet transmission, which is not applicable in this situation.
C. Using dedicated equipment for the client is crucial to prevent the spread of MRSA and ensure infection control.
D. Turning on the HEPA filtration system is not a standard practice for dressing changes and does not specifically address the infection control needs of the client with MRSA.

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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?

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Naxlex Comprehensive Predictor Exams

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