A nurse is observing an assistive personnel (AP) providing 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.

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

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

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

Answer and Explanation

The Correct Answer is A

Choice A rationale

Removing gloves outside an isolation room increases contamination risk by allowing pathogens to spread to other surfaces or areas. Standard precautions require immediate disposal of gloves inside isolation rooms to maintain strict infection control measures.

Choice B rationale

Encouraging clients to look down during ambulation aids balance and reduces fall risks. This recommendation follows safety guidelines and does not indicate incorrect AP behavior requiring intervention or correction by the nurse.

Choice C rationale

Maintaining a water temperature of 40° C (104° F) aligns with best practices for foot care, ensuring comfort and preventing skin damage. It does not necessitate intervention since this is a safe and appropriate nursing action.

Choice D rationale

Applying water-soluble lubricant to the nares reduces dryness from oxygen therapy, improving patient comfort. This practice aligns with evidence-based guidelines for oxygen care and does not warrant nurse intervention as it enhances client outcomes.

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Correct Answer is A

Explanation

Choice A rationale

Closing the door prevents the spread of smoke and fire to other areas, protecting clients and staff. This action aligns with the RACE (Rescue, Alarm, Contain, Extinguish) protocol to contain fire hazards effectively while prioritizing safety.

Choice B rationale

Reporting fire details is crucial but should occur after ensuring client safety and containment of the fire. Early containment by closing the door prevents escalation, reducing the risk of harm to others in the facility.

Choice C rationale

Activating the fire alarm is important; however, containment actions such as closing the door take precedence to manage the immediate fire hazard. Containment minimizes risks while allowing subsequent emergency actions to occur.

Choice D rationale

Turning off electrical equipment is important but secondary in prioritization. Containing the fire’s spread by closing the door first ensures broader safety for all. Electrical disconnection can follow once the immediate hazard is managed.

A. Report the incident to the charge nurse. B. Log the previous user out of the system. C. Complete an incident report. D. Offer to conduct a unit in-service on client confidentiality.

Correct Answer is B

Explanation

Choice A rationale

Reporting the incident to the charge nurse is important for managerial awareness but not the immediate priority to secure the client’s health information. Addressing data security should precede reporting to ensure confidentiality is maintained swiftly, minimizing risks of breach or misuse.

Choice B rationale

Logging out the previous user immediately secures the unattended screen and protects client data from unauthorized access. This action directly eliminates the risk of information exposure, aligning with HIPAA regulations to safeguard privacy as the nurse’s first responsibility.

Choice C rationale

Completing an incident report documents the breach for accountability but does not address the immediate issue of exposed client data. While necessary for administrative purposes, it must follow direct actions to secure the health information promptly.

Choice D rationale

Conducting an in-service on confidentiality supports education but fails to resolve the immediate issue. This preventive measure should be considered after mitigating the risk to client data, emphasizing proactive rather than reactive measures.

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A nurse is observing an assistive personnel (AP) providing 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

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