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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 B

Explanation

Rationale:

A. Protective isolation could be managed by any qualified RN, LPN, or AP depending on the complexity.

B. A client actively dying and requiring IV pain medication needs specialized assessment and pain management, which is appropriate for an RN.

C. A client 3 days postoperative requires ongoing care that can be managed by an LPN with supervision.

D. Frequent ambulation is a task that can be managed by an AP, though supervision may be needed.

A. Assisting a client to cough and deep breathe B. Application of antiembolic stockings C. Administration of an enema D. Assessing a client's sacrum for edema

Correct Answer is D

Explanation

Rationale:

A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.

B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.

C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.

D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?

Correct Answer is B

Explanation

A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?

Correct Answer is D

Explanation

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 delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

A nurse is caring for a client who is postoperative. Exhibits Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply

A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?

A nurse tells another nurse that she thinks he did not provide adequate care for a client who underwent hip arthroplasty. Which of the following responses by the nurse demonstrates assertiveness?

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?