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. Supporting the client in her personal decision respects her autonomy and right to make decisions about her own healthcare.
B. Referring the client to a counselor can be appropriate, but the primary response should be to support the client's decision.
C. Encouraging the client not to give up may not be appropriate if the client has made a well- considered decision to refuse further treatment.
D. Suggesting that the client talk with a breast cancer survivor may provide emotional support but should not be used as a means to persuade the client to undergo further treatment if she has made an informed decision to refuse.

A. Granulex B. Hydrocolloid C. Proteolytic enzyme D. Cortisone cream

Correct Answer is B

Explanation

A. Granulex is a topical medication used for wound care, but it may not be the first choice for a stage II pressure ulcer.
B. Hydrocolloid dressings are appropriate for stage II pressure ulcers, providing a moist environment to support healing and protecting the wound from contamination.
C. Proteolytic enzymes are used for debridement of necrotic tissue and may not be the primary choice for a stage II pressure ulcer.

D. Cortisone cream is a topical steroid that may be used for certain skin conditions but is not typically the first-line treatment for pressure ulcers.

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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?

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