The nurse enters the adolescent client's room after the unlicensed assistive personnel (UAP) has finished bathing the client and finds used tissues on the floor by the bed, the client's bedpan on the foot of the bed, and the bath basin drying on
top of the bedside table. What is the nurse's priority action? 1. Reprimand the UAP.
2. Instruct the client to clean her room.
3. Discard tissues and put the bedpan and basin away.
4. Call housekeeping to clean the room.
3
Rationale: It is the nurse's responsibility to maintain a hygienic environment, so the nurse should straighten the room to prevent injury as the highest priority. While the nurse might want to teach the UAP to straighten the room as part of the bath, it is not the first priority. Telling the teen to clean her room is a parental action, not a nursing action. Housekeeping isn't necessary, because the room is not dirty; it is cluttered, and this can be handled by the nurse.
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