Which skills demonstrated by assistive personnel require immediate follow-up. Select the "3" findings that require immediate follow-up.
AP 1-Quickly pulls fire alarm, then proceeds to remove the client from room. AP 3-Raised bedrails of the bed for client who was reported not alert or oriented, and was sleeping.
AP 2-Verifies with nurse the order in which protective equipment should be removed.
AP 7- While disinfecting portable vital sign monitor wore gloves and washed hand prior to leaving room.
AP 6 - During simulation, which included assisting client into bed, there was no observed handwashing.
AP 5-Following simulation, was unable to identify the locations of alarms on medical surgical unit.
AP 4-Successfully completed skills of simulation including emptying the client's trash can
Correct Answer : A,D,E
Rationale:
A. While pulling the fire alarm is correct, removing the client from the room without following the full RACE sequence (Remove, Alarm, Confine, Extinguish/Evacuate) is incorrect. The immediate safety measures should include ensuring that the alarm is activated before evacuation and confining the fire if possible.
B. Verifying the order of protective equipment removal with the nurse shows a good practice and adherence to proper infection control procedures.
C. Washing hands prior to leaving the room after disinfecting equipment indicates proper infection control practice.
D. Handwashing is a crucial aspect of infection control. Failure to perform hand hygiene during or after patient care increases the risk of infection transmission. Immediate follow-up is needed to ensure that proper hand hygiene practices are adhered to.
E. Knowing the locations of alarms is vital for effective fire safety. Inability to identify these locations indicates a significant gap in preparedness for emergencies. Immediate follow-up is necessary to ensure that staff are familiar with fire safety procedures and equipment locations.
F. Successfully completing the skills in simulation, including emptying the client's trash can, shows adherence to task requirements but is not a critical issue requiring immediate follow-up compared to the other findings.
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Correct Answer is B
Explanation
Rationale:
A. Fill the bath basin with tap water that is 39° C (102.2° F) is too warm for bathing; the recommended water temperature is typically around 37°C (98.6°F) to prevent burns or discomfort.
B. Pull the curtain around the client's bed ensures privacy for the client during the bath, which is important for maintaining dignity and confidentiality.
C. Wash the client's arms and hands first is not necessarily the first step; typically, washing the face and then moving to the rest of the body is preferred.
D. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus is incorrect as it should be done from the inner canthus to the outer canthus to avoid spreading any discharge across the eye.
Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. Applying an ambulation alarm can help alert staff if the client tries to move independently, thus reducing the risk of falls.
B. Restraints should only be used as a last resort and require a physician’s order. They should not be used routinely for fall prevention.
C. Instructing the client in the use of the call light empowers them to request assistance, which can help prevent falls.
D. Raising all side rails can be considered a restraint and may increase the risk of falls or injury. It is not a recommended practice for fall prevention.
E. Checking on the client hourly ensures ongoing monitoring and timely intervention if needed, which is effective in preventing falls.