A licensed practical/vocational nurse (LP/VN) enters a client's room, finding the bed in high position, both top-side rails down (which violate facility policy) and the call light within reach
There is a puddle of spilt bath water on the floor by the bed. The nurse recognizes that the unlicensed assistive personnel (UAP) stepped out of the room during the bath to gather some linen she forgot. Which action is the priority?
A) Return the bed to low position and place top-side rails up
B) Wipe up the spilled water
C) Discuss the situation with the UAP
D) Write an incident report
Ans: A
Feedback:
The nurse's top priority is to provide a safe environment for the client first by working from client to surrounding environment. Step 1: Return the bed to low position and place top side rails up. Step 2: Wipe up the spilled water. Step 3: Discuss the situation with the UAP. (Rationale: The UAP stepped out and will return, so the nurse needs to privately discuss the situation with the UAP and reach an acceptable resolution to provide safe care for the client). Step 4: Write an incident report. (Rationale: Charting occurs after care is provided, and part of creating and maintaining the safe environment is step 3 input to include in the incident report).
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