A nurse manager observes assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?
Help the AP assist the client with the transfer
Demonstrate the proper client transfer technique to the AP
Instruct the AP to request assistance when unsure about a task
Refer the AP to the facility procedure manual
The Correct Answer is A
A. Helping the assistive personnel immediately ensures the client’s safety, which is the nurse’s top priority. Incorrect transfer techniques can lead to falls or injury, so the nurse must intervene right away to prevent harm.
B. Demonstrating proper transfer technique is important for education, but it should occur after the immediate safety issue is resolved.
C. Instructing the AP to request assistance when unsure is appropriate teaching, but it does not address the immediate risk to the client during the transfer.
D. Referring the AP to the procedure manual is not a priority in an active situation where the client could be injured. Education and reference can occur later.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Advising the newly licensed nurse to complete less time-consuming tasks first may not address the underlying issue of difficulty focusing and prioritizing care effectively.
b. Recommending that the newly licensed nurse take time to plan at the beginning of his shift can help him organize tasks and prioritize care more effectively.
c. While offering to provide care for his clients while he takes a break is supportive, it does not address the underlying issue of difficulty focusing and prioritizing care.
d. Asking other staff members to take over some of his tasks may be necessary in some situations but should not be the first intervention. Helping the nurse develop strategies to improve focus and organization is more appropriate.
Correct Answer is A
Explanation
Rationale:
a. Administering an enema for a scheduled endoscopy is within the scope of practice for an LPN. It involves a task that is repetitive, stable, and does not require critical thinking.
b. Developing an initial plan of care for a client with sickle cell anemia involves critical thinking and assessment, which are within the scope of practice for an RN.
c. A client transferring from the CCU after a myocardial infarction requires close monitoring and assessment, which are typically within the scope of practice for an RN.
d. Teaching a newly admitted client about self-administration of insulin involves education, assessment, and critical thinking, which are typically within the scope of practice for an RN.
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