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. Delaying surgery in a life-threatening situation could endanger the client, so waiting for parental consent is not required under emergency circumstances.
B. The pediatrician does not have the authority to provide implied consent; this legal principle applies directly to the care team in emergency situations.
C. In emergency situations where a minor requires immediate, life-saving treatment and a parent or legal guardian is not available, implied consent allows the surgeon to proceed with necessary interventions to prevent harm.
D. An adult cousin does not have legal authority to provide consent for a minor’s treatment unless specifically designated as a legal guardian.
Correct Answer is B
Explanation
A. Keeping the water heater set below 60° C (140° F) is important for preventing scalding but may not be feasible for everyone, as some people prefer hotter water for hygiene.
B. Disposing of unused medications is a critical safety measure to prevent accidental ingestion or misuse, making it the best choice for home safety education.
C. Setting the refrigerator temperature to 7.2° C (45° F) is higher than the recommended maximum of 4° C (40° F) to prevent food spoilage and bacterial growth.
D. Running electrical cords under carpeting poses a fire hazard and should be avoided, thus is not suitable advice for a safety presentation.