A nurse and assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Document the client's respiratory rate in 1 hr.

Monitor the client for an allergic reaction for 30 min.

Check the client's response to the medication in 1 hr.

Evaluate the client for therapeutic eﬀects in 30 min.

Answer and Explanation

The Correct Answer is A

After the nurse administers a PRN pain medication to a client, the nurse can assign the assistive personnel (AP) to document the client's respiratory rate in 1 hour. This is within the scope of practice of an AP.

The other tasks are not appropriate for an AP to perform.

Monitoring the client for an allergic reaction and evaluating the client for therapeutic eﬀects are both nursing assessments that should be performed by the nurse.

Checking the client's response to the medication is also a nursing assessment that should be performed by the nurse.

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Correct Answer is B

Explanation

b. "Everyone who lives in the home will need medication."

The nurse should inform the guardian that everyone who lives in the home will need medication when reinforcing teaching about enterobiasis. Enterobiasis, also known as pinworm infection, is highly contagious, and it can easily spread from person to person within the household. Treating only the aﬀected individual may not be sufficient to eliminate the infection completely, as other household members may also be infected or at risk of reinfection.

Explanation for the other options:

a. "One dose of medication is all that will be necessary." Enterobiasis is typically treated with a medication regimen that involves taking multiple doses over a period of time. This is to ensure that all stages of the pinworm life cycle are targeted and eradicated. A single dose is usually not sufficient to eliminate the infection completely.

c. "Allow the child to take tub baths instead of showers." The choice of tub baths or showers does not directly impact the treatment or prevention of enterobiasis. Both methods of bathing can be used, but it is important to maintain good hygiene practices, such as regular handwashing and proper cleaning of the perianal area, to reduce the risk of reinfection.

d. "Wash all clothes and bed linens in cold water." While proper hygiene practices and laundering of clothes and bed linens are important in preventing the spread of enterobiasis, using cold water alone may not be sufficient. Washing clothes and bed linens in hot water (at a temperature of at least 60°C or 140°F) is recommended to kill any pinworm eggs that may be present.

A. Inform visitors to remain at least 3 feet away from the client. B. Apply sterile gloves when entering the client's room. C. Leave all equipment that is used routinely in the client's room D. Place the client in a negative-pressure airﬂow room

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale:

While maintaining a distance of 3 feet can reduce the risk of direct contact transmission, it is not the most effective measure for contact isolation precautions.
Contact isolation aims to prevent the spread of pathogens that can be transmitted through direct or indirect contact with the infected person or contaminated objects.
A distance of 3 feet may not be sufficient to prevent transmission via droplets or fomites (inanimate objects that can harbor infectious agents).

Choice B rationale:

Sterile gloves are not routinely required for contact isolation precautions.
They are primarily used for sterile procedures or when there is a risk of exposure to blood or body fluids.
For contact isolation, standard clean gloves are usually sufficient to protect against transmission via direct contact.

Choice C rationale:

Leaving equipment that is used routinely in the client's room is a crucial part of contact isolation precautions.
This practice prevents the spread of infection by minimizing the movement of potentially contaminated items outside of the isolation room.
Equipment like stethoscopes, blood pressure cuffs, and thermometers should be dedicated to the client's use and not shared with other patients.

Choice D rationale:

Negative-pressure airflow rooms are used for airborne isolation precautions, which are designed to prevent the spread of pathogens that can be transmitted through the air.
Contact isolation does not specifically require a negative-pressure room, as the primary mode of transmission is through direct or indirect contact, not airborne particles.

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A nurse and assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Nursing Test Bank

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