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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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Correct Answer is C

Explanation

A. Risk for infection:

Neuropathy can compromise the ability to detect injuries or wounds on the feet. Consequently, there's a risk of wounds going unnoticed, becoming infected, and leading to serious complications. While preventing infection is important, the primary concern in this scenario is preventing the occurrence of wounds or skin breakdown in the first place.

B. Impaired physical mobility:

Impaired physical mobility may be a concern for clients with neuropathy, especially if it affects their ability to walk or perform activities of daily living. However, in this scenario, the client is reporting increasing numbness and tingling in the lower extremities, indicating a sensory issue rather than a motor one. Therefore, while physical mobility is important, it may not be the immediate priority for promoting foot care in this case.

C. Risk for impaired skin integrity:

This option addresses the potential risk of skin breakdown or damage due to decreased sensation in the lower extremities, which is characteristic of neuropathy. With increasing numbness and tingling, there's a higher risk that the client may not be able to perceive injuries or pressure points, leading to skin damage or ulceration. Preventing skin integrity issues is crucial to avoid complications such as infections or wounds.

D. Self-care deficit:

Neuropathy can indeed impact a person's ability to perform self-care activities, including foot care. However, the priority in this scenario is to prevent complications related to neuropathy, such as skin integrity issues, rather than addressing deficits in self-care abilities. While self-care education and support may be necessary in the long term, immediate intervention to prevent skin breakdown takes precedence.

A. Regular exercise. B. Smoking cessation. C. Low fat diet. D. Stress reduction.

Correct Answer is B

Explanation

A. Regular exercise:

Regular exercise is important for overall cardiovascular health and can help reduce the risk of developing heart disease. However, smoking cessation is more crucial because smoking is a significant risk factor for heart disease and quitting smoking has immediate and long-term benefits for heart health.

B. Smoking cessation:

Smoking is a major risk factor for heart disease as it damages the blood vessels, increases blood pressure, reduces oxygen supply to the heart, and promotes the formation of blood clots. Encouraging smoking cessation is essential for reducing the risk of heart disease and improving overall health.

C. Low-fat diet:

Adopting a low-fat diet can help lower cholesterol levels and reduce the risk of heart disease, but it may not be as critical as smoking cessation for individuals with a family history of cardiac disease.

D. Stress reduction:

While stress reduction techniques such as relaxation exercises, meditation, and mindfulness can be beneficial for heart health, addressing smoking cessation is more urgent for individuals with a family history of cardiac disease, as smoking is a more significant risk factor for heart disease.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is C

Explanation

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

Correct Answer is B

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?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

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?

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self care at home?

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

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?