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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Storing unused patches in the refrigerator is not necessary for transdermal scopolamine patches. Refrigeration is not a requirement for their storage.
Choice B rationale:
Applying the patch prior to traveling is the correct choice. Transdermal scopolamine patches are used to prevent motion sickness. Applying the patch before the journey allows the medication to be absorbed before exposure to motion, ensuring its effectiveness during travel.
Choice C rationale:
Placing the patch on the upper arm is a specific and correct instruction for applying transdermal scopolamine patches. The patch should be placed on a clean, dry, and hairless area of the skin, preferably behind the ear or on the upper arm.
Choice D rationale:
Replacing a dislodged patch onto the same location is incorrect. If the patch becomes dislodged, it should be replaced with a new patch on a different, clean, and dry area of the skin. Reapplying a dislodged patch to the same spot may result in uneven absorption and reduced effectiveness.
Correct Answer is D
Explanation
A. A butterfly needle is not typically used for accessing implanted ports.
B. An angiocatheter is not typically used for accessing implanted ports.
C. A 25-gauge needle might be too small for accessing an implanted port.
D. Correct. A noncoring needle (Huber needle) is specifically designed for accessing implanted venous access ports to minimize damage to the port septum and prevent leakage.
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