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 A

Explanation

a. Document an objective description of the situation:

It is important to start by documenting the observed behavior objectively. This documentation can serve as a factual record of the incident.

b. Schedule a formal meeting with the LPN within 48 hours:

While addressing the issue promptly is important, scheduling a formal meeting should come after documenting the situation. The initial step is to gather information and document observations.

c. Interview clients about the nurse’s actions:

Interviewing clients may be necessary later in the investigation process, but the immediate action should be to document the observed behavior and then proceed with a more formal investigation if needed.

d. Check the unit narcotic records for discrepancies:

The issue at hand appears to be related to alcohol use rather than narcotics. While discrepancies in narcotic records might be a concern, it may not be the most relevant action based on the situation described.

A. “You can ask an AP to teach a simple task to a client.” B. “You should assign tasks you are unfamiliar with to an experienced AP.” C. “If you are unsure about an AP’s ability, observe them performing the task.” D. “The person who delegates a task is not held accountable for the outcome.”

Correct Answer is C

Explanation

a. "You can ask an AP to teach a simple task to a client."

While assistive personnel may assist with client education under the supervision of a licensed nurse, the primary responsibility for teaching tasks to clients usually rests with licensed healthcare providers.

b. "You should assign tasks you are unfamiliar with to an experienced AP."

Delegating tasks to assistive personnel should be based on their competency and the complexity of the task, not necessarily on the nurse's familiarity with it. It is essential to delegate tasks that the AP is trained and competent to perform.

c. "If you are unsure about an AP’s ability, observe them performing the task."

This is the correct statement. It emphasizes the importance of assessing an assistive personnel's competence by observing their performance before delegating tasks, especially if there is uncertainty about their abilities.

d. "The person who delegates a task is not held accountable for the outcome."

This statement is incorrect. The person delegating a task is ultimately accountable for ensuring that the task is performed correctly and safely. Delegation does not relieve the delegator of accountability.

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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?

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