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 D
Explanation
Choice A rationale:
An increase in heart rate by 10 beats per minute when moving from a supine to a sitting position is a normal physiological response to compensate for decreased venous return and maintain cardiac output. This response does not indicate orthostatic hypotension.
Choice B rationale:
An increase in diastolic blood pressure by 10 mm Hg when moving from a supine to a sitting position is a normal response to compensate for the effects of gravity on blood flow. It helps maintain perfusion to vital organs and does not indicate orthostatic hypotension.
Choice C rationale:
Heart palpitations can occur due to various reasons, including anxiety or arrhythmias, but they are not specific signs of orthostatic hypotension. This symptom alone does not confirm the presence of orthostatic hypotension.
Choice D rationale:
A decrease in systolic blood pressure by 25 mm Hg or more when moving from a supine to a sitting position indicates orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more within 3 minutes of standing up. This condition can cause dizziness, lightheadedness, or fainting and can be a side effect of antihypertensive medications or other underlying medical conditions.
Correct Answer is B
Explanation
Choice A rationale:
Changing the inner cannula on a tracheostomy is within the legal scope of practice for registered nurses. Nurses are trained to perform tracheostomy care, including changing the inner cannula. This procedure is within the nursing scope of practice and does not require a physician's intervention.
Choice B rationale:
Inserting a tunneled central venous catheter (such as a Hickman line) is a specialized procedure that generally falls under the scope of practice for advanced practice nurses (such as nurse practitioners or clinical nurse specialists) or physicians. RNs typically do not have the required training or authority to perform this invasive procedure.
Choice C rationale:
Irrigation of an external ear canal is within the legal scope of practice for registered nurses. Ear irrigation is a common nursing procedure used to remove impacted cerumen (earwax) and foreign bodies from the ear canal. Nurses are trained to perform this procedure safely and effectively.
Choice D rationale:
Administering blood products, including platelet transfusions, is within the legal scope of practice for an RN. RNs are responsible for preparing, verifying, and administering blood products according to institutional policies and procedures. This includes monitoring the patient during and after the transfusion for any adverse reactions.
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