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 A
Explanation
Rationale:
A. The physiologic status of the clients is the most critical factor in assigning tasks, ensuring that clients with more complex needs receive appropriate care.
B. Social relationships are secondary to patient safety and quality of care.
C. Personal comfort level should not influence assignment decisions; patient care needs are the priority.
D. Assigning the most experienced nurse to complex clients is appropriate, but it should be based on client needs rather than just experience alone.
Correct Answer is D
Explanation
Rationale:
A. "There are no provider's prescriptions available." is related to background information but does not describe the current situation of the client.
B. "The client was found unconscious on the floor in her home." provides information about the situation but not the current clinical background.
C. "The client should be seen by a neurologist." is a recommendation for further action and should be included in the "Recommendation" section of SBAR, not "Background."
D. "The client is disoriented. Pupils are slow to respond to light." provides relevant background information about the client's current condition, which is necessary for the SBAR "Background" step.