The practical nurse (PN) hears an older resident of a long-term care facility shouts at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take?
Tell the resident and the UAP that shouting is not permitted.
Enter the room and tell the UAP to leave the room immediately.
Tell both of them to lower their voices in consideration of other residents.
Report the incident and the UAP for further action by the nurse-manager.
The Correct Answer is B
A. Tell the resident and the UAP that shouting is not permitted: While setting behavioral limits is important, addressing both parties simultaneously does not stop the immediate verbal conflict or protect the resident from potential emotional harm.
B. Enter the room and tell the UAP to leave the room immediately: The priority is to protect the resident from verbal abuse and de-escalate the confrontation. Removing the UAP stops the conflict, ensures the resident’s emotional safety, and allows the PN to assess the resident’s condition and provide reassurance.
C. Tell both of them to lower their voices in consideration of other residents: Asking them to quiet down minimizes the impact on others but fails to address the abusive nature of the exchange. The situation requires immediate intervention to stop the staff’s inappropriate behavior.
D. Report the incident and the UAP for further action by the nurse-manager: Reporting is necessary and should occur after the immediate threat has been resolved. The PN should first stop the confrontation and protect the resident before following up with appropriate documentation and notification to the nurse-manager.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Compare the client's current vital signs with vital signs taken earlier in the day: Vital signs can provide objective data but may not accurately reflect pain intensity or quality. They cannot replace the client’s subjective report, which is the most reliable indicator of pain.
B. Ask the client to provide a detailed description about the quality of the pain: Obtaining the client’s description allows the PN to validate the presence, severity, and characteristics of pain. This subjective data guides appropriate interventions and ensures individualized pain management.
C. Review the medication record and note when the client last received an analgesic: While reviewing medication timing is important for planning pain relief, it does not confirm whether the client is currently experiencing pain or its intensity.
D. Consult with the charge nurse about the manifestations that the client is exhibiting: Consulting another nurse may be helpful for collaborative care, but first-hand assessment and obtaining the client’s subjective report are necessary before escalation.
Correct Answer is A
Explanation
A. Gloves: Gloves are typically the most contaminated piece of PPE. Removing them first prevents the spread of pathogens to other parts of the body or environment and reduces the risk of self-contamination.
B. Cap: The cap is usually less contaminated than gloves and gown. It is removed after higher-risk items to minimize potential contamination.
C. Face mask: The face mask should be removed after gloves and gown, ensuring that hands are clean afterward to avoid touching the face and spreading contaminants.
D. Disposable gown: The gown is removed after gloves but before the face mask, rolling it inside out to contain contamination. It is important, but gloves present the highest immediate contamination risk and are removed first.
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