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 A

Explanation

A. A compromised airway is an immediate life-threatening condition that requires rapid intervention to ensure oxygenation. In mass casualty triage, this client is tagged red (immediate) because airway issues are often quickly reversible with prompt care.

B. A brief loss of consciousness suggests a possible head injury, but if the client is currently stable, it is not the highest priority. This client would likely receive a yellow tag (delayed).

C. Fixed pupils indicate severe neurological damage and are often associated with a poor prognosis. These clients are typically tagged black (expectant/deceased) rather than red.

D. Burns covering 70% of the body surface area have a very low likelihood of survival, especially in a mass casualty situation. These clients are generally tagged black (expectant) because resources are directed toward those with better chances of survival.

A. Bite block B. Yankauer suction device C. Large-handled utensils D. Nasal cannula and oxygen

Correct Answer is B

Explanation

- A. Bite block: This is not the correct choice. A bite block is used to prevent a patient from biting down on tubes or other equipment, not typically required for a patient with dysphagia.
- B. Yankauer suction device: This is the correct choice. A Yankauer suction device is used to clear the oral cavity of secretions or food particles, which is essential for a patient with dysphagia to prevent aspiration.
- C. Large-handled utensils: While these may be helpful for a patient with dysphagia to feed themselves more easily, they are not as critical as ensuring the airway is clear of obstructions.
- D. Nasal cannula and oxygen: This equipment would be necessary if the patient had respiratory issues, but it is not specifically related to the management of dysphagia.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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