A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?

Demonstrate the proper use of personal protective equipment.

Offer to assist the UAP with the collection of the specimen.

Provide the UAP with the infection control policy.

Determine the UAP's knowledge about HIV transmission.

Answer and Explanation

The Correct Answer is D

Choice A reason: Demonstrating the proper use of personal protective equipment is important, but not the first action. The charge nurse should first assess the UAP's level of understanding and address any misconceptions or fears about HIV transmission.

Choice B reason: Offering to assist the UAP with the collection of the specimen may be helpful, but not the first action. The charge nurse should first educate the UAP about HIV transmission and infection control measures, and then evaluate the UAP's competence and confidence in performing the task.

Choice C reason: Providing the UAP with the infection control policy is relevant, but not the first action. The charge nurse should first explain the rationale and principles of infection control to the UAP, and then refer to the policy as a guideline and resource.

Choice D reason: Determining the UAP's knowledge about HIV transmission is the first and most appropriate action for the charge nurse to take, as it will help identify any gaps or misinformation that may cause fear or anxiety in the UAP. The charge nurse should then provide accurate and evidence-based information about HIV transmission, prevention, and treatment, and answer any questions or concerns that the UAP may have.

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Correct Answer is C

Explanation

Choice A Reason: Recording the patient's pulse volume distal to the IV site is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.
Choice B Reason: Reapplying cold compresses to the site of the extravasation is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP.
Choice C Reason: Disposing of the IV tubing after the infusion is discontinued is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice D Reason: Teaching the patient about the need to keep the extremity elevated is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP.

A. Subtotal thyroidectomy performed one hour ago, receiving a unit of packed red blood cells. B. Combined partial and full-thickness burns on the anterior chest three days ago. O2 saturation is 92%. C. Renal transplant yesterday, complaining of flank pain and who states, "it's hot in here." D. Nephrotic syndrome diagnosed 2 days ago, decreased serum protein level and mild edema.

Correct Answer is D

Explanation

Choice A Reason: A subtotal thyroidectomy is a major surgery that involves the removal of part of the thyroid gland. The client may have complications such as bleeding, infection, hypocalcemia, or vocal cord damage. The client also needs close monitoring of vital signs, blood transfusion, and airway patency. This client is not stable enough to be transferred to a general unit.

Choice B Reason: A combined partial and full-thickness burn is a serious injury that involves damage to the epidermis, dermis, and underlying tissues. The client may have complications such as infection, fluid loss, hypovolemia, shock, or respiratory distress. The client also needs wound care, pain management, fluid replacement, and oxygen therapy. This client is not stable enough to be transferred to a general unit.

Choice C Reason: A renal transplant is a major surgery that involves the replacement of a diseased kidney with a healthy one from a donor. The client may have complications such as rejection, infection, bleeding, thrombosis, or urinary obstruction. The client also needs immunosuppressive therapy, anti-infective therapy, fluid and electrolyte balance, and pain management. This client is not stable enough to be transferred to a general unit.

Choice D Reason: Nephrotic syndrome is a kidney disorder that causes excessive protein loss in the urine, leading to low serum protein levels and edema. The client may have complications such as infection, thromboembolism, or malnutrition. The client needs diuretic therapy, protein replacement, dietary modification, and infection prevention. This client is relatively stable and can be transferred to a general unit.

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A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?

Nursing Test Bank

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