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An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?

Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care.

Send the UAP to be fitted for a particulate filter mask Immediately so the UAP can provide care to this client.

Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client.

Before changing assignments, determine which staff members have fitted particulate filter masks.

Answer and Explanation

The Correct Answer is C

A. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care:

This option might be tempting but is not appropriate because the UAP should be properly equipped with the correct protective gear before any contact with the client. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.

B. Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client:

This action is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N95, which is used for airborne precautions. This option indicates a misunderstanding of the type of precautions needed for bacterial meningitis.

C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client:

This is the correct course of action. Bacterial meningitis requires droplet precautions, which only require a standard face mask. The UAP can safely provide care using a standard mask.

D. Before changing assignments, determine which staff members have fitted particulate filter masks:

While it is prudent to know which staff members are fitted for particulate filter masks, this is not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. A well approximated incision site:

A properly healing surgical incision typically appears well approximated, meaning the wound edges are closely aligned and held together with sutures or staples. This indicates that the wound is healing as expected and that the risk of infection and complications is minimized.

B. Erythema and serosanguineous exudate:

Erythema (redness) and serosanguineous exudate (pinkish fluid composed of serum and blood) can be normal findings in the early stages of wound healing, but they may also indicate inflammation or infection if they persist or worsen over time.

C. Eschar and slough in the wound:

Eschar (dead tissue) and slough (yellow or white necrotic tissue) are signs of tissue necrosis or delayed wound healing. They indicate that the wound is not healing properly and may require intervention such as debridement to remove dead tissue and promote healing.

D. Beefy red granulation tissue:

Beefy red granulation tissue is a sign of the proliferative phase of wound healing and indicates that the wound is healing from the bottom up. While granulation tissue is a positive sign of healing, it typically appears later in the healing process rather than one week post-surgery.

A. Keeps a pair of gloves in uniform pocket. B. Uses sterile gloves when handling body fluids. C. Dons sterile gloves when caring for clients with HIV. D. Puts on new gloves when entering a client's room.

Correct Answer is D

Explanation

A. Keeping a pair of gloves in a uniform pocket:

While it may be convenient to carry gloves, this action alone does not necessarily indicate an understanding of appropriate gloving procedures. Simply having gloves readily available does not ensure that they are used correctly or in accordance with infection control protocols.

B. Using sterile gloves when handling body fluids:

This action indicates an understanding of the need for sterile gloves when handling potentially infectious body fluids. However, it's important to note that not all situations require sterile gloves, and the use of sterile gloves should be based on the specific clinical context and infection control guidelines.

C. Donning sterile gloves when caring for clients with HIV:

While wearing gloves when caring for clients with HIV is important for infection control, not all situations require sterile gloves. The use of sterile gloves should be based on the specific clinical context and infection control guidelines.

D. Putting on new gloves when entering a client's room:

This action demonstrates an understanding of the importance of donning clean gloves when entering a client's room to prevent the spread of infection. It indicates adherence to standard precautions and proper infection control practices, making it the most appropriate choice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client one week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Correct Answer is A

Explanation

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action Indicates that a UAP understands gloving procedures?

Correct Answer is D

Explanation

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which Intervention is most important for the nurse to implement before leaving the client alone?

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

A client with chronic fecal Incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which Intervention should the nurse Implement?