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. Asking other staff nurses does not address the immediate concern of the client and could lead to gossip or unnecessary complications.
B. Addressing the concern with the specific staff nurse directly is appropriate to understand any issues and to see if there is a valid reason for the client’s request.
C. Recommending transfer without understanding the issue could be premature and might not address the root of the problem.
D. Notifying human resources is a step that may be needed later but should not be the first action; the manager should first address the issue with the staff nurse.
Correct Answer is C
Explanation
Rationale:
A. Reporting the observation to the nurse caring for that client is important but not the immediate priority.
B. Informing the nursing supervisor is necessary but should be done after assessing the situation directly.
C. Approaching the man and asking why he is making copies is the most immediate and direct action. It allows the nurse to assess the situation and determine if the man has legitimate access to the client's medical record or if further action is needed.
D. Notifying hospital security may be necessary if the man’s actions are unauthorized, but the first step is to gather more information.