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A nurse is observing an assistive personnel (AP) provide care to a group of clients. Which of the following actions by the AP requires intervention by the nurse?

A.

Removing gloves before leaving an isolation room

B.

Filling a basin with water at 40° C (104° F) when providing foot care

C.

Instructing a client to look down at their feet when being assisted to ambulate

D.

Applying water-soluble lubricant to the nares of a client who is receiving oxygen

Answer and Explanation

The Correct Answer is B

A. Removing gloves before leaving an isolation room is appropriate practice and helps prevent the spread of infection.  

 

B. Filling a basin with water at 40° C (104° F) is too hot for foot care and could lead to burns or injury; water temperature for foot care should be comfortably warm, typically around 37°C (98.6°F).  

 

C. Instructing a client to look down at their feet when being assisted to ambulate is a safety measure that can help the client maintain balance and avoid tripping.  

 

D. Applying water-soluble lubricant to the nares of a client receiving oxygen is a standard practice to prevent dryness and does not require intervention.


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View Related questions

Correct Answer is A

Explanation

A. Morphine is classified as a Schedule II controlled substance due to its high potential for abuse and dependence, but it is accepted for medical use.

B. Schedule III substances have a lower potential for abuse than Schedule II, which does not apply to morphine.

C. Schedule I substances are considered to have no accepted medical use and a high potential for abuse, such as heroin, which does not include morphine.

D. Schedule IV substances have a lower abuse potential than Schedule III, making this classification incorrect for morphine.

Correct Answer is D

Explanation

A. Asking each nurse for information about the problem is essential, but it should occur after addressing the immediate need for privacy.

B. Listening to the concerns of each staff nurse is important, but doing so in a private area ensures confidentiality and reduces further escalation.

C. Discussing ways to resolve the conflict is necessary, but first creating a safe and private environment is vital for open communication.

D. Moving the staff nurses to a private area is the first step to ensure they can discuss their conflict without external pressures or interruptions, which facilitates a more constructive dialogue.

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