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A nurse manager along with members of the nurse practice committee are conducting a skills day for assistive personnel in the medical surgical unit to validate competency.

Fire Safety

Objectives:

All Staff will:

Know the location of exits, alarms, fire extinguishers, and oxygen turnoff valves.

Make sure equipment does not block fire doors.

Know the evacuation plan for the unit and the facility.

Enact RACE sequence for fire response.

Remove

Alarm

Confine

Extinguish/Evacuate

Fall Safety

Infection Control

Objectives

The staff will:

Perform proper hand hygiene.

Properly put on and remove personal protective equipment.

Gloves

Gowns

Masks

Properly disinfect patient care equipment

Review levels of precaution (standard, airborne, droplet, contact)

Which skills demonstrated by assistive personnel require immediate follow-up. Select the "3" findings that require immediate follow-up.

AP 1-Quickly pulls fire alarm, then proceeds to remove the client from room. AP 3-Raised bedrails of the bed for client who was reported not alert or oriented, and was sleeping.

AP 2-Verifies with nurse the order in which protective equipment should be removed.

AP 7- While disinfecting portable vital sign monitor wore gloves and washed hand prior to leaving room.

AP 6 - During simulation, which included assisting client into bed, there was no observed handwashing.

AP 5-Following simulation, was unable to identify the locations of alarms on medical surgical unit.

AP 4-Successfully completed skills of simulation including emptying the client's trash can

Answer and Explanation

Correct Answer : A,D,E

A. While pulling the fire alarm is correct, removing the client from the room without following the full RACE sequence (Remove, Alarm, Confine, Extinguish/Evacuate) is incorrect. The immediate safety measures should include ensuring that the alarm is activated before evacuation and confining the fire if possible.

B. Verifying the order of protective equipment removal with the nurse shows a good practice and adherence to proper infection control procedures.

C. Washing hands prior to leaving the room after disinfecting equipment indicates proper infection control practice.

D. Handwashing is a crucial aspect of infection control. Failure to perform hand hygiene during or after patient care increases the risk of infection transmission. Immediate follow-up is needed to ensure that proper hand hygiene practices are adhered to.

E. Knowing the locations of alarms is vital for effective fire safety. Inability to identify these locations indicates a significant gap in preparedness for emergencies. Immediate follow-up is necessary to ensure that staff are familiar with fire safety procedures and equipment locations.

F. Successfully completing the skills in simulation, including emptying the client's trash can, shows adherence to task requirements but is not a critical issue requiring immediate follow-up compared to the other findings.

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Correct Answer is C

Explanation

Rationale:

A. Inform the state medical board for an immediate investigation is not the initial step; concerns should first be reported to appropriate facility personnel.

B. Counsel the provider to determine the cause of the substance abuse is not the nurse’s role; this is a serious issue that requires reporting rather than counseling.

C. Notify the nursing supervisor of the concerns is the appropriate initial step to address the issue according to facility protocol.

D. Encourage clients to change to a different provider is not within the nurse’s scope of practice for handling the provider's behavior and does not address the root issue.

A. Assessment B. Situation C. Background D. Recommendation

Correct Answer is A

Explanation

Rationale:

A. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.

B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.

C. Background provides context or history relevant to the situation but does not include current vital signs.

D. Recommendation involves suggesting actions or solutions but does not include the current condition details.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN?

A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change?

A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?

A nurse is caring for a client whose family member requests to view the client's medical record. Which of the following responses should the nurse make?

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A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?

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