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. Places food on the stronger side of the client’s mouth: Placing food on the stronger side of the mouth helps the client chew and swallow more effectively and safely. This compensates for weakness on one side, reducing the risk of choking and aspiration.

B. Positions the client at a 30-degree angle prior to eating:A 30-degree angle is insufficient to reduce the risk of aspiration in clients with dysphagia. The client should be positioned in an upright sitting position (90 degrees) to facilitate safer swallowing and reduce the risk of choking or aspirating food.

C. Instructs the client to hyperextend their neck when swallowing:Hyperextending the neck (tilting the head back) can actually increase the risk of aspiration by opening the airway, making it easier for food or liquids to enter the lungs. The client should be encouraged to tuck the chin slightly when swallowing to protect the airway.

D. Has the client sit upright for 20 minutes following meals: While sitting upright after meals is beneficial for preventing reflux and aspiration, 20 minutes is not sufficient. The client should remain upright for at least 30 minutes after meals to further reduce the risk of aspiration.

A. “I will ask your mother’s primary care provider to speak with you.” B. “You will have to speak directly to your mother about her treatment.” C. “What would you like to know about your mother’s treatment.” D. “I cannot provide this information to you without your mother’s consent.”

Correct Answer is D

Explanation

a. "I will ask your mother's primary care provider to speak with you."This response does not address the issue of confidentiality and consent. The nurse should not assume that the provider will discuss the treatment without the client's consent.

B.“You will have to speak directly to your mother about her treatment.”This response correctly redirects the child to the client but does not fully explain the importance of consent and confidentiality, which are crucial in maintaining professional and ethical standards.

C.“What would you like to know about your mother’s treatment.”This response might imply a willingness to share information without the client’s consent, which would be a violation of confidentiality and privacy laws.

D.“I cannot provide this information to you without your mother’s consent.”Correct. This response clearly states the need for the client’s consent before any information can be shared, adhering to the principles of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) regulations.

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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

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