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 D

Explanation

A. Implementing a fall prevention plan is an important step but comes after identifying those at risk.
B. Reviewing current literature is important for understanding evidence-based practices, but it should come after identifying and assessing the specific risk factors in the facility.
C. Notifying staff of the increased fall rate is essential but doesn't directly address the root cause; it's more reactive than proactive.
D. Identifying clients who are at risk for falls is the initial step to intervene and prevent further incidents, forming the foundation for a targeted fall prevention plan.

A. A client who is 3 days postoperative following abdominal surgery is ready for discharge B. A client who has Alzheimer's disease and bacterial pneumonia with newly onset restlessness C. A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 D. A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL

Correct Answer is B

Explanation

A. A client ready for discharge, if stable and prepared for discharge, does not require immediate assessment.
B. Restlessness in a client with Alzheimer's and bacterial pneumonia could indicate a change in condition, potentially signaling an urgent issue that needs immediate assessment.
C. While pain management is important, the sudden onset of restlessness in a client with cognitive impairment and pneumonia takes priority.
D. An elevated fasting blood glucose level in a newly admitted diabetic client requires attention but might not be as immediately critical as the acute change in behavior seen in option B.

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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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