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.

Help the AP assist the client with the transfer.

Refer the AP to the facility procedure manual.

Demonstrate the proper client transfer technique for the AP.

Answer and Explanation

The Correct Answer is B

A.   Instruct the AP to request assistance when unsure about a task: While this is an important instruction, the immediate priority is ensuring the safety of the client during the transfer.
B.   Help the AP assist the client with the transfer: This is the correct answer. The nurse should intervene immediately to ensure the safety of the client during the transfer. Providing assistance to the AP in safely transferring the client is the most appropriate action to take first.
C.   Refer the AP to the facility procedure manual: While facility procedures are important, referring to the manual may not address the immediate need to correct the incorrect transfer and ensure client safety.
D.   Demonstrate the proper client transfer technique for the AP: While education and demonstration of correct techniques are important, the immediate priority is to intervene and ensure the safety of the client during the transfer.

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Correct Answer is D

Explanation

A. The facility ethics committee can provide guidance and recommendations, but they do not have the authority to override a competent client's decision regarding their own medical treatment. Their role is advisory rather than decisive.

B. While a client's refusal based on religious beliefs must be respected, it is not the primary deciding factor in this scenario. The key issue is the client's understanding and informed consent, regardless of the reason for refusal.

C. If the partner is the client's durable power of attorney for health care, they can make decisions on behalf of the client only if the client is deemed incompetent. In this case, the client is competent and has made their own decision.

D. The client's understanding of the risks associated with refusing the procedure is crucial. Informed consent requires that the client comprehends the potential consequences of their decision, ensuring that their refusal is based on a clear understanding of the risks involved.

A. An adolescent who was admitted and refuses to speak to their parents B. A toddler who cries whenever their parent enters the examination room C. A preschooler who was previously toilet trained and now requires diapers in the hospital D. A school-age child who has several abrasions on their lower legs

Correct Answer is C

Explanation

A. An adolescent who refuses to speak to their parents may be experiencing emotional distress, but this behavior does not necessarily require immediate intervention by the nurse.
B. A toddler who cries in the presence of their parent is displaying separation anxiety, which is a common reaction in young children and does not typically require intervention by the nurse unless it persists or escalates.
C. A preschooler who was previously toilet trained and now requires diapers may indicate regression, which could be a sign of emotional distress or physical illness and warrants further assessment and intervention by the nurse.
D. A school-age child with abrasions on their lower legs may require wound care and assessment, but this does not indicate an immediate need for intervention by the nurse unless there are signs of infection or other complications.

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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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