NCLEX-PN® ExaminationCoordinated CareHard
An LPN is supervising a nursing assistant (NA) who is providing care to a client with a history of falls. The LPN observes the NA leaving the client's bed in a high position after providing hygiene. What is the most appropriate initial action for the LPN to take?
- ANotify the charge nurse about the NA's unsafe practice.
- BRemind the NA to lower the bed and explain the rationale.
- CDocument the NA's error in the client's chart.
- DImmediately lower the client's bed to the lowest position.
Show answer & explanationAnswer & explanation
Correct answer: D. Immediately lower the client's bed to the lowest position.
The immediate priority is client safety. Leaving a client's bed in a high position, especially for a client with a history of falls, poses an immediate risk. The LPN must first rectify the unsafe situation before addressing the NA's performance.
Why the other options are wrong
- A. Notifying the charge nurse is appropriate for ongoing performance issues, but the LPN must first ensure the client's immediate safety.
- B. While essential for teaching and performance improvement, this action should follow immediately after ensuring the client's safety by lowering the bed.
- C. Documentation is important for incident reporting and performance management, but it is not the immediate action to prevent harm.
Supervision: Immediate Safety Intervention
The LPN's responsibility to immediately intervene and correct an unsafe situation observed during supervision of unlicensed assistive personnel (UAP) to ensure client safety.
- Client safety is paramount.
- Immediate intervention for unsafe acts.
- Followed by teaching and feedback.
Memory trick: When 'DANGER' is near, 'DIRECTLY' 'DEAL' with the threat.