The practical nurse (PN) observes an unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in the high fowlers position. Which action should the PN take?
Assume care of the client immediately.
Remain in the room to supervise the UAP.
Instruct the UAP to lower the bed for safety.
Determine if the UAP would like assistance.
The Correct Answer is C
The correct answer is choice C: Instruct the UAP to lower the bed for safety.
Choice C rationale: When bathing a bedfast client, the bed should be in a flat or low position to reduce the risk of the client sliding down, falling, or experiencing discomfort or injury. By instructing the UAP to lower the bed, the PN ensures client safety during the bathing process.
Choice A rationale: Assuming care of the client immediately might be unnecessary. The PN should first address the safety concern and then determine if additional intervention is needed.
Choice B rationale: While supervising the UAP may be appropriate in certain situations, the priority in this case is to address the immediate safety concern by instructing the UAP to lower the bed. The PN can then decide if supervision or assistance is required.
Choice D rationale: Determining if the UAP would like assistance is considerate, but it is not the priority in this situation. Ensuring client safety by lowering the bed should be addressed first. The PN can then assess whether the UAP needs any help or guidance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: In emergencies where immediate surgery is required to save a life, implied consent is assumed if the patient is unresponsive and no family is available. Ethical and legal guidelines allow proceeding without signed consent to avoid delays that could be life-threatening.
Choice B rationale: A close friend typically does not have legal authority to provide informed consent for medical procedures unless they have been designated as a healthcare proxy. Therefore, this action would not be legally appropriate in this situation.
Choice C rationale: Seeking an emergency court order for surgery could cause delays that are detrimental to the patient's health. In life-threatening situations, implied consent is sufficient, and prompt action is necessary to save the patient's life.
Choice D rationale: Continuing to provide life support without proceeding with surgery may not be sufficient to address the life-threatening condition. Immediate surgical intervention is necessary, and implied consent allows this to be done without waiting for a guardian.
Correct Answer is A
Explanation
Choice B rationale:
Giving the wife a straw to help facilitate the client's drinking is not the most appropriate action in this situation. The client's facial paralysis and inability to move his left side could be indicative of a possible stroke or cerebral vascular accident (CVA). Before attempting to give the client fluids, it is essential to assess his swallowing reflex to prevent aspiration and ensure safety. Using a straw may not address the underlying issue.
Choice C rationale:
Assisting the wife and carefully giving the client small sips of water without assessing the swallowing reflex can be risky. If the client has impaired swallowing, this action could lead to aspiration and further complications. Assessing the client's ability to swallow is the priority to ensure safe oral intake.
Choice D rationale:
Obtaining thickening powder before providing any more fluids is premature without first assessing the client's swallowing ability. Thickened liquids may be necessary if the client has dysphagia, but the nurse should assess the client's condition and consult with the healthcare provider before making this decision. Assessing the swallowing reflex is the first step in determining the appropriate course of action.
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