An older client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves 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.

Assign the UAP to provide care for another client and assume full care of the client.

Review the need for the UAP to wear a face mask while in close contact with the client.

Answer and Explanation

The Correct Answer is D

Given the older client's history of heart failure and current diagnosis of influenza, it is important for the nurse to ensure that appropriate infection control measures are being followed while providing care. In this scenario, the nurse observes the UAP wearing a gown and gloves to assist the client with sitting up to eat lunch. The nurse should review the need for the UAP to wear a face mask while in close contact with the client. Influenza is spread through respiratory droplets, so wearing a face mask is an important infection control measure to prevent the spread of the virus.

Reminding the UAP to apply a fitted respirator mask before entering the client's room may not be necessary in this situation, as a regular face mask may be sufficient for preventing the spread of influenza.

Additionally, the nurse should instruct the UAP to notify the nurse of any changes in the client's respiratory status. This will allow the nurse to monitor the client's condition closely and intervene promptly if needed.

Assigning the UAP to provide care for another client and assuming full care of the client may not be necessary, as long as appropriate infection control measures are being followed.

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Correct Answer is A

Explanation

Choice A rationale:

Diazepam is a benzodiazepine medication commonly used to manage seizures, including those associated with alcohol withdrawal. It acts as a central nervous system depressant, reducing excessive neuronal activity and helping control seizures. Diazepam is considered the first-line medication for managing alcohol withdrawal seizures due to its efficacy and safety profile when administered under medical supervision.

Choice B rationale:

Naltrexone is an opioid receptor antagonist used primarily to treat alcohol and opioid dependence. It does not have a direct anticonvulsant effect and is not indicated for managing seizures associated with alcohol withdrawal. Naltrexone works by blocking the effects of opioids and reducing cravings, making it valuable in substance use disorder treatment but not in the acute management of seizures.

Choice C rationale:

Acamprosate is another medication used in the treatment of alcohol dependence. It helps maintain abstinence from alcohol by reducing cravings and withdrawal symptoms. However, it does not have anticonvulsant properties and is not used to manage seizures associated with alcohol withdrawal. Acamprosate is more focused on supporting long-term sobriety and preventing relapse in individuals

A. Round the edges of toenails when trimming. B. Soak feet twice daily. C. Use moisturizing lotion between the toes. D. Wear clean cotton socks every day.

Correct Answer is D

Explanation

Incorrect. Rounding the edges of toenails can lead to ingrown toenails, which should be avoided.
B. Incorrect. Soaking feet twice daily can lead to dry skin and potentially increase the risk of infection, so it's not recommended.
C. Incorrect. Using moisturizing lotion between the toes can also increase the risk of moisture-related skin issues. It's better to keep the area between the toes dry.
D. Correct. Wearing clean cotton socks helps maintain proper foot hygiene and prevents moisture accumulation, reducing the risk of fungal infections.

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An older client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

Explanation

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