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?
Removing gloves before leaving an isolation room
Filling a basin with water at 40° C (104° F) when providing foot care
Instructing a client to look down at their feet when being assisted to ambulate
Applying water-soluble lubricant to the nares of a client who is receiving oxygen
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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Correct Answer is C
Explanation
A. An abdominal CT scan with contrast typically requires specific informed consent due to the use of contrast material and potential risks associated with it.
B. An esophagogastroduodenoscopy is an invasive procedure that necessitates special informed consent due to its risks and potential complications.
C. The insertion of an NG tube to low intermittent suction is considered a routine procedure that is generally included under the client's general consent for treatment.
D. The administration of fresh frozen plasma involves specific risks and usually requires informed consent because of the implications of blood product administration.
Correct Answer is D
Explanation
A. QD (every day) is not an approved abbreviation due to the potential for misinterpretation, so it should not be used.
B. HS (at bedtime) is also not recommended as it can be confused with "half-strength," so it is not an approved abbreviation.
C. SQ (subcutaneous) is not commonly used in current practice as abbreviations may lead to errors; the term should be written out as "subcut" or "subcutaneously."
D. PO (by mouth) is an accepted and approved abbreviation used to indicate that a medication is to be taken orally, making it the correct choice for inclusion in the in-service.