A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

Instruct the AP to request assistance when unsure about a task.

Demonstrate the proper client transfer technique for the AP.

Help the AP assist the client with the transfer.

Refer the AP to the facility procedure manual.

Answer and Explanation

The Correct Answer is C

A. Instructing the AP to request assistance when unsure about a task is important for future situations, but it does not immediately address the current incorrect transfer, which could pose a risk to the client.
B. Demonstrating the proper client transfer technique for the AP directly addresses the immediate issue, ensuring the client is safely transferred and the AP learns the correct method through observation and practice.
C. Helping the AP assist the client with the transfer ensures the client's safety in the moment, but it does not provide the AP with the knowledge or skills needed to perform the task correctly in the future.
D. Referring the AP to the facility procedure manual is useful for long-term learning, but it does not provide the immediate guidance needed to correct the current unsafe transfer.

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Correct Answer is B

Explanation

A. Notifying risk management before initiating treatment is not necessary in this emergent situation; patient care should take precedence.
B. In emergent situations where a patient lacks decision-making capacity and requires
immediate treatment to prevent harm, consent for treatment can be assumed based on the principle of implied consent.
C. Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful.
D. Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation.

A. Two nurses had a heated disagreement about a scheduling issue. B. A client is refusing care from an assistive personnel of the opposite gender. C. Three staff members have called to say they will be absent. D. No transport assistance is available to take a client to physical therapy.

Correct Answer is C

Explanation

- A: While resolving conflicts is important to maintain a healthy work environment, it may not immediately affect patient care and safety.
- B: Client preferences should be respected, but this situation can usually be resolved by reassigning staff without immediate risk to patient safety.
- C: Staff absences can critically impact patient care due to inadequate staffing, which can lead to increased workload for present staff and compromise patient care.
- D: Transport issues, although they need to be addressed, do not usually pose an immediate threat to patient safety compared to inadequate staffing. Physical therapy can often be rescheduled without significant harm to the patient.

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A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

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