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 B

Explanation

A. A client who has dementia and exhibits aphasia: While aphasia can be concerning, it is not necessarily indicative of immediate risk to the client or others.
B. A client who has bipolar disorder and displays constant pacing: This client is the highest priority because constant pacing may indicate agitation or escalating anxiety, which could lead to agitation or aggression and require immediate intervention to prevent harm to the client or others.
C. A client who has schizophrenia and uses neologisms: Neologisms, although indicative of disorganized thinking, do not necessarily present an immediate safety concern compared to constant pacing.
D. A client who has depressive disorder and has poor personal hygiene: While poor personal hygiene is important to address for the client's well-being, it may not present an immediate safety risk compared to the behaviors exhibited by the client in option B.

A. A client who has a compromised airway B. A client who experienced a brief loss of consciousness C. A client who has fixed pupils D. A client who has major burns covering 70% of their body

Correct Answer is A

Explanation

- A. A client with a compromised airway requires immediate intervention to secure breathing, which is a top priority in triage situations. Without a patent airway, the client is at high risk for suffocation and rapid deterioration.
- B. A client who experienced a brief loss of consciousness may require observation and further assessment, but does not necessarily need immediate life-saving intervention if consciousness has been regained and there are no other signs of airway, breathing, or circulation compromise.
- C. A client with fixed pupils may indicate severe brain injury and, depending on the context, could be considered for a red tag. However, without additional information on breathing and circulation status, it is not the most definitive choice for immediate intervention.
- D. A client with major burns covering 70% of their body is critically injured and will require extensive medical care, but the immediate life-threatening issue in a triage situation is the airway compromise, not the burns themselves.

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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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