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?

 

Choice A rationale

Notifying the pharmacy about a suspected missed medication does not resolve the client's concern or confirm the issue. This action is relevant if a dispensing error is suspected but is not the priority in this case.

Choice B rationale

Reporting the concern to the charge nurse ensures proper investigation and resolution. The charge nurse can verify administration records, interview involved staff, and address the client’s report, maintaining continuity of care and accountability.

Choice C rationale

Documenting the client’s claim in the nurses’ notes is essential for legal and medical records but does not initiate any resolution. Prioritizing investigation helps determine the facts and address discrepancies in care delivery.

Choice D rationale

Querying the previous nurse could provide insights but risks breaching professional decorum without proper channels. Involving the charge nurse ensures that the concern is addressed transparently and objectively. .

• A. Removing gloves before leaving an isolation room: ✅ Appropriate. Gloves should be removed before exiting to prevent contamination.

• B. Instructing a client to look down at their feet when ambulating: ❌ Unsafe. This increases the risk of falls. Clients should be encouraged to look straight ahead to maintain balance and awareness of their surroundings.

• C. Filling a basin with water at 40°C (104°F): ✅ Safe and appropriate temperature for foot care.

• D. Applying water-soluble lubricant to the nares of a client receiving oxygen: ✅ Acceptable. Water-soluble lubricants help prevent dryness and are safe to use with oxygen therapy.