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 client should sign the informed consent if they are alert, oriented, and capable of making decisions. The client's ability to understand the procedure and its implications is key to valid informed consent.
B. The client's son, who has a durable power of attorney would only sign the consent if the client were not competent or unable to understand the procedure, which is not the case here.
C. The client's partner may be involved in the decision-making process but does not have the legal authority to sign the consent unless designated as a legal representative.
D. The client's daughter, who is the primary caregiver would also not have the legal authority to sign the consent unless she holds a durable power of attorney or the client is deemed incapable of giving consent.
Correct Answer is C
Explanation
Rationale:
A. Asking about discharge is a general inquiry that does not require immediate follow-up unless it’s related to specific discharge planning.
B. Changing the dressing is a routine postoperative care task and doesn’t necessarily require follow-up unless there’s a concern about the procedure.
C. Not receiving medications is a critical issue that needs immediate attention to address potential gaps in treatment.
D. Not knowing how to use the remote control is a minor issue that does not require clinical follow-up.