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27.27.ID: 283590536A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. The RN would conclude that the nursing assistant is performing the procedure incorrectly after observing that the nursing assistant: Stands behind the client Correct Stands on the right side of the client Positions the free hand on the client’s shoulder Incorrect Grasps the security belt in the midspine area of the small of the client’s back Rationale: When walking with a client, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the client’s back. The nurse should position the free hand at the shoulder area so that the client may be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at his or her feet.Test-Taking Strategy: Note the strategic word “incorrectly.” This word indicates a negative event query and the need to select the unsafe action by the nursing assistant. Visualizing the action in each option will direct you to the unsafe and incorrect action. Review the procedure for assisting ambulation of a client with weakness if you had difficulty with this question.Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques(7th ed., pp. 250,
253). St. Louis: Mosby.Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Leadership/Management Awarded 0.0 points out of 1.0 possible points. 28.28.ID: 283589656A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation? Telling the nurse that it is inappropriate to report other nurses Incorrect Providing an in-service educational session on aseptic technique for everyone on the nursing unit Informing the nurse who reported the occurrence that intravenous ports do not need to be cleaned with alcohol before medication administration Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated Correct Rationale: Intravenous ports must be cleaned with alcohol (or another antiseptic as designated by agency policy) before access. The nurse manager should handle this problem directly with thenurse who is using incorrect technique by first reviewing the nurse’s skills checklist to determine whether this skill has ever been performed by the nurse and validated. There is no information inthe question to indicate that an in-service educational session is needed for everyone on the nursing unit. As a part of professional responsibility to maintain quality care, nurses are required to report instances of clinical incompetence.