A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning
gloves and a gown to assist the client. Which action should the nurse take?
Remind the UAP to apply a fitted respirator mask before entering the client's room.
Instruct the UAP to notify the nurse of any changes in the client's respiratory status.
Review the need for the UAP to wear a face mask while in close contact with the client.
Assign the UAP to provide care for another client and assume full care of the client.
The Correct Answer is C
Choice A reason: Reminding the UAP to apply a fitted respirator mask before entering the client's room is not a necessary action for the nurse to take. A respirator mask is a type of personal protective equipment (PPE. that filters out airborne particles and droplets that may contain infectious agents. A respirator mask is required for clients who have or are suspected of having airborne diseases, such as tuberculosis, measles, or chickenpox. Influenza is a respiratory disease that is transmitted by droplet contact, not by airborne contact.
Choice B reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is not a specific action for the nurse to take. Respiratory status is an assessment of the client's breathing pattern, rate, depth, effort, and oxygen saturation. Respiratory status can be affected by various factors, such as infection, inflammation, obstruction, or injury. The nurse should monitor the client's respiratory status regularly and teach the UAP to report any signs or symptoms of respiratory distress, such as dyspnea, cyanosis, wheezes, or cough.
Choice D reason: Assigning the UAP to provide care for another client and assuming full care of the client is not a feasible action for the nurse to take. The nurse should delegate tasks according to the scope of practice, competency, and availability of staff. The nurse should not reassign staff without a valid reason or without consulting with other team members. The nurse should also not assume full care of a client unless it is necessary or appropriate. The nurse should supervise and evaluate the UAP's performance and provide feedback and guidance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: This is incorrect because providing a diet low in phosphorus is not indicated for a client with cirrhosis of the liver. Phosphorus restriction is more relevant for clients with renal failure, not liver failure.
Choice B reason: This is correct because noting signs of swelling and edema is an essential intervention for a client with cirrhosis of the liver. Swelling and edema are signs of fluid retention and portal hypertension, which are common complications of liver disease.
Choice C reason: This is incorrect because increasing oral fluid intake to 1,500 mL daily is not advisable for a client with cirrhosis of the liver. Fluid restriction may be necessary to prevent fluid overload and ascites, which are common complications of liver disease.
Choice D reason: This is correct because monitoring abdominal girth is an important intervention for a client with cirrhosis of the liver. Abdominal girth measurement can indicate the presence and severity of ascites, which is a common complication of liver disease.
Choice E reason: This is correct because reporting serum albumin and globulin levels is a vital intervention for a client with cirrhosis of the liver. Serum albumin and globulin levels can reflect the liver's synthetic function and indicate the extent of liver damage.
Correct Answer is D
Explanation
Choice A: Which medication works best for you? This is not the most important question, as it does not address the current status or risk of the client. The medication history is a part of the assessment, but it does not help identify the content or impact of the hallucinations.
Choice B: When do you hear voices? This is not the most important question, as it does not address the current status or risk of the client. The frequency and timing of the hallucinations are a part of the assessment, but they do not help identify the content or impact of the hallucinations.
Choice C: How do you cope with the voices? This is not the most important question, as it does not address the current status or risk of the client. The coping strategies are a part of the assessment, but they do not help identify the content or impact of the hallucinations.
Choice D: What are the voices saying? This is the most important question, as it addresses the current status and risk of the client. The content and impact of the hallucinations are a part of the assessment, as they can help identify if the client is experiencing command hallucinations, which may instruct them to harm themselves or others.
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