A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

Volunteer to provide an inservice about infection control.

Speak with the AP when he exits the room about the appropriate protocol.

Provide the appropriate PPE to the AP.

Notify the charge nurse about the AP's need for training.

Answer and Explanation

The Correct Answer is C

A. Volunteer to provide an inservice about infection control. While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.

B. Speak with the AP when he exits the room about the appropriate protocol. Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.

C. Provide the appropriate PPE to the AP. This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.

D. Notify the charge nurse about the AP's need for training. Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

Love and belonging. Maslow's Hierarchy of Needs outlines a pyramid of human needs, starting from basic physiological needs at the bottom and progressing to higher-level psychological and self-fulfillment needs. Love and belonging are higher-level needs, and individuals typically address them after their basic physiological needs are met. Basic needs like food, water, and shelter take precedence over higher-level emotional needs. In this case, the client's most immediate need would be to satisfy their hunger and thirst.

Choice B rationale:

Psychological security. Psychological security is another higher-level need related to safety and a sense of protection. While it is important, it is not the most immediate need according to Maslow's Hierarchy of Needs. The client would prioritize fulfilling their basic physiological needs before seeking psychological security.

Choice C rationale:

Self-actualization. Self-actualization is the highest level of need in Maslow's Hierarchy, encompassing personal growth, fulfillment, and achieving one's potential. It is a need that individuals pursue once their lower-level needs are satisfied. Since the question pertains to the first need the client would seek to meet, self-actualization is not the correct answer.

Choice D rationale:

Food and water. Food and water are fundamental physiological needs that form the base of Maslow's Hierarchy. These needs must be met before an individual can move on to addressing higher-level needs. Without addressing the need for sustenance, the client's ability to seek love, belonging, security, or self-actualization would be compromised.

A. Encourage the client to ambulate frequently. B. Encourage the client to increase fluid intake. C. Encourage regular use of the incentive spirometer. D. Encourage coughing and deep breathing.

Correct Answer is C

Explanation

Choice A rationale:

Encouraging the client to ambulate frequently is important for preventing complications associated with immobility, such as deep vein thrombosis and muscle atrophy. However, it is not a direct intervention for promoting the thinning of respiratory secretions.

Choice B rationale:

Encouraging the client to increase fluid intake is a valuable intervention to help thin respiratory secretions. However, the most effective method mentioned here is the use of the incentive spirometer, which directly assists the client in taking deep breaths and enhancing lung function.

Choice C rationale:

Encouraging regular use of the incentive spirometer is a crucial intervention for promoting the thinning of respiratory secretions. Incentive spirometry helps prevent atelectasis (collapse of lung tissue) and promotes deep breathing, which aids in clearing secretions and maintaining lung health.

Choice D rationale:

Encouraging coughing and deep breathing is generally important for maintaining lung health and preventing complications like pneumonia. However, the specific action of using the incentive spirometer is more targeted and effective for promoting respiratory secretion clearance in clients with pneumonia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client in a Community Clinic. In accordance with Maslow's Hierarchy of needs, which of the following needs will the client seek to meet first?

Correct Answer is D

Explanation

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Correct Answer is C

Explanation

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?

A nurse is performing a cardiovascular assessment on a healthy client. In which of the following anatomical landmarks would the nurse expect to palpate the client's Point of Maximal Impulse (PMI)?

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

A nurse is assessing a patient who has chronic bronchitis. The nurse should expect the patient's chest to be which of the following shapes?

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?