A client with influenza requires assistance in transferring to the bedside commode.
The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. What action should the nurse take?

The correct answer is choiceB. Confirm that the gown is tied securely at the neck and waist.

Choice A rationale:

Reminding the UAP to wash hands frequently while in the room is important for infection control, but it is not the immediate priority in this scenario. The UAP has already donned gloves, which are part of the personal protective equipment (PPE) required for contact precautions. Hand hygiene is crucial before and after patient contact and after removing gloves, but ensuring the gown is properly secured takes precedence to prevent contamination.

Choice B rationale:

Confirming that the gown is tied securely at the neck and waist is essential to ensure that the UAP is fully protected from potential contamination.A properly secured gown prevents the UAP’s clothing from coming into contact with the patient or contaminated surfaces, which is critical in maintaining effective contact precautions.

Choice C rationale:

Assisting the UAP with the application of a face mask or face shield is necessary for droplet or airborne precautions, not specifically for contact precautions.Since the scenario involves contact precautions, the focus should be on the gown and gloves.

Choice D rationale:

Helping the UAP reposition the gown sleeve over the glove edges is not necessary because the UAP has already secured the tops of the gloves over the gown sleeves.This method is appropriate as it prevents the sleeves from becoming contaminated.

A. Estimating blood pressure based on the strength or quality of the radial pulse is not a reliable method. Pulse volume can provide only a very rough sense of perfusion but does not give a numeric measurement of systolic or diastolic pressure. Relying on this method could lead to inaccurate assessment, delayed recognition of hypotension or hypertension, and inappropriate clinical interventions, putting the client at risk.

B. While it is essential to document the limitations in obtaining vital signs, documentation alone does not resolve the issue. The client still needs accurate and timely blood pressure measurements for safe monitoring and care, especially if they have a condition that could compromise hemodynamic stability. Simply recording that measurement is not possible fails to meet the standard of care.

C. Using a previous blood pressure reading is unsafe because it does not reflect the client’s current condition. Vital signs can change rapidly due to fluid shifts, pain, medications, or other medical issues. Documenting an old reading can mislead the care team and result in inappropriate interventions or delayed response to changes in the client’s status.

D. This is the most appropriate and safe action. When the upper extremities are unavailable due to casts or injury, alternative validated sites, such as the popliteal artery, should be used. The nurse can teach the UAP how to position the client correctly, flexing the knee while supine, to allow proper cuff placement and accurate measurement. This ensures the client receives safe and reliable monitoring, and the staff is competent in using alternative techniques when standard sites are inaccessible.