A nurse manager observes an assistive personnel 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. Help the AP assist the client with the transfer.

While it is important to instruct the AP to seek assistance when unsure, this does not immediately address the safety of the client during the current incorrect transfer.

b. Demonstrate the proper client transfer technique to the AP.

Demonstrating the proper technique is an important step, but it should come after ensuring the immediate safety of the client. This can be done once the client is safely transferred.

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

Correct. The nurse's first priority should be the safety of the client. By immediately assisting the AP with the transfer, the nurse ensures the client's safety and prevents potential injury.

d. Refer the AP to the facility procedure manual.

Referring the AP to the procedure manual is important for future reference, but it does not address the immediate risk to the client. This action can be taken after ensuring the client's safety and demonstrating the correct technique.

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Correct Answer is B

Explanation

A. The client covers electrical cords with a throw rug: This action is unsafe. Placing a throw rug over electrical cords poses a fire hazard and could lead to tripping. Electrical cords should be secured and kept out of walkways to prevent accidents.

B. The client set the water heater to 49 degrees Celsius (120 degrees Fahrenheit): The water heater should be set to a maximum temperature of 49°C (120°F) to prevent scalding injuries, which are a concern for older adults whose skin may be more sensitive. Temperatures higher than this increase the risk of burns.

C. The client has the refrigerator set to 7.2 degrees Celsius (45 degrees Fahrenheit): This temperature is too high. A refrigerator should be set at or below 4°C (40°F) to properly preserve food and prevent bacterial growth. Setting the refrigerator to 7.2°C (45°F) can result in foodborne illnesses.

D. The client has a standard height toilet seat in the bathroom: This may be inadequate for older adults, particularly those with mobility issues. A raised toilet seat may be recommended for better comfort and safety, as it reduces the risk of falls while sitting down or standing up.

A. Complete an incident report about the breach of client confidentiality B. Reassign the AP to other clients on the unit C. Instruct the AP to discontinue the conversation D. Notify the client’s provider about the incident

Correct Answer is C

Explanation

a. Complete an incident report about the breach of client confidentiality:

While documenting the incident is important, completing an incident report alone may not address the immediate need to stop the breach of confidentiality.

b. Reassign the AP to other clients on the unit:

Reassignment may be considered after addressing the immediate issue, but it doesn't directly address the inappropriate conversation.

c. Instruct the AP to discontinue the conversation:

This is the correct immediate action. The nurse should intervene and instruct the assistive personnel to stop discussing the client's care in a non-secure location like the cafeteria.

d. Notify the client’s provider about the incident:

While notifying the client's provider may be necessary in certain situations, the immediate concern is to stop the breach of confidentiality and address the inappropriate conversation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is C

Explanation

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