A nurse observes an assistive personnel (AP) empty an indwelling urinary catheter drainage bag while not wearing gloves. Which of the following interventions should the nurse take first?

Provide the AP with a copy of the unit's policy.

Notify the charge nurse about the incident.

Talk with the AP about the technique used.

Conduct an in-service on standard precautions.

Answer and Explanation

The Correct Answer is C

A.   Providing the AP with a copy of the unit's policy may be done but is not the first step. Direct communication is important for immediate feedback.
B.   Notifying the charge nurse is appropriate but may not be the first action when direct communication with the AP can address the issue.
C.   Talking with the AP about the technique used is the first and immediate action to address the observed lapse in infection control practices.
D.   Conducting an in-service on standard precautions is a broader intervention and may be considered after addressing the immediate concern with the AP.

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Correct Answer is A

Explanation

A. The right task involves ensuring that the delegated task is appropriate for delegation. In this case, obtaining an oral temperature should have been the correct task; however, the AP
performed the axillary temperature, indicating a deviation from the right task.
B. Right communication involves clear and effective communication between the nurse and the assistive personnel but is not directly related to the task performed.
C. Right person involves ensuring that the task is delegated to a competent and qualified

individual. The issue in this scenario is with the task itself, not the competency of the individual.

D. Right circumstance involves ensuring that the conditions are appropriate for delegation. While the circumstance is important, the primary concern in this case is the mismatch between the task and the method of temperature measurement.

A. The client places one crutch on each side when assuming a sitting position. B. The client places weight on the axillae when walking. C. The client moves the unaffected leg onto a step first when descending stairs. D. The client has slightly flexed elbows when ambulating with crutches.

Correct Answer is D

Explanation

A) Placing one crutch on each side when assuming a sitting position is not indicative of safe crutch use as it does not provide adequate support or balance during the transition from standing to sitting.
B) Placing weight on the axillae, or underarms, can cause nerve damage due to the pressure on the radial nerve located there; therefore, this is not a safe practice.
C) When descending stairs, the affected leg should be moved first, followed by the crutches and then the unaffected leg, to maintain balance and safety. Therefore, moving the unaffected leg onto a step first is not the safest option.
D) Having slightly flexed elbows allows for proper distribution of weight and helps in maintaining balance while ambulating with crutches, making it the correct and safe method.

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A nurse observes an assistive personnel (AP) empty an indwelling urinary catheter drainage bag while not wearing gloves. Which of the following interventions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?

Correct Answer is A

Explanation

A nurse is evaluating a client's use of crutches. Which of the following observations indicates safe use of this equipment?

Correct Answer is D

Explanation

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