A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles.
For which of the following actions by the newly licensed nurse should the charge nurse intervene?
The nurse places the client on airborne precautions.
The nurse has the client wear a mask for transport to radiology.
The nurse wears an N95 respirator when performing client care.
The nurse ensures the client's room maintains a positive airflow.
The Correct Answer is D
A. The nurse places the client on airborne precautions: This is appropriate, as measles is transmitted via airborne particles. B. The nurse has the client wear a mask for transport to radiology: This is correct. A surgical mask minimizes the risk of spreading airborne pathogens during transport. C. The nurse wears an N95 respirator when performing client care: Correct. An N95 respirator is necessary for protection against airborne diseases like measles. D. The nurse ensures the client's room maintains a positive airflow: This is incorrect and requires intervention. Clients with airborne infections like measles must be placed in negative pressure rooms, which prevent contaminated air from escaping into other areas. Positive airflow increases the risk of transmission to others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
The correct answer is B, C, and E.
- A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
- B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
- C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
- D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
- E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.
Correct Answer is A
Explanation
A. Performing gastrostomy feedings through an established gastrostomy tube is within the scope of practice for an AP, as it is a routine, non-complex task.
B. Evaluating the effectiveness of pain medication requires assessment skills, which fall under the nurse’s scope of practice.
C. Providing client care instructions requires nursing judgment and should be done by the nurse.
D. Teaching a client how to measure their blood pressure involves client education, which is the nurse’s responsibility.
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