An unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment, verbalizing they have not been fitted for a particulate filter mask. Which action should the nurse take?

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

Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client.

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

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

Answer and Explanation

The Correct Answer is D

A.   This action involves assessing which staff members are appropriately equipped to handle the situation. While it is useful to know which staff are fitted with particulate filter masks, this step does not directly address the UAP’s immediate concern or resolve the issue with the current assignment.
B.   Pertussis (whooping cough) is a disease that requires droplet precautions, which generally means using a standard surgical mask rather than a particulate filter mask. However, it’s crucial to ensure that the UAP is aware of and follows the correct infection control measures.
C.   Pertussis requires droplet precautions, which usually involve wearing a standard surgical mask, not a particulate filter mask (N95). Fitting for an N95 mask is generally reserved for airborne precautions.
D.   This action addresses the immediate need by allowing the UAP to perform tasks that do not involve close personal care (such as taking vital signs) with a standard face mask, which is appropriate for droplet precautions. It also ensures that the UAP receives proper fitting for a particulate filter mask if needed for other tasks or future assignments.

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Correct Answer is D

Explanation

A. While medical diagnoses can influence the type of care a client needs, functional capacity is the most important factor when determining the best living environment.
B. Age and gender can be factors to consider, but they are not as important as functional capacity. For example, an older adult with a high level of functional independence may be able to live independently, even if they are elderly.
C. This is not relevant to the decision of where an older adult client should live.
D. The client's functional capacity is the most important factor to consider when determining the best living environment. If the client requires significant assistance with ADLs, a nursing home or assisted living facility may be the most appropriate option.

A. Protein. B. Hemoglobin. C. White blood cell count D. Sodium.

Correct Answer is D

Explanation

A. While protein levels are important in assessing overall nutritional status and can indicate conditions like malnutrition or liver disease, they are not the primary focus in the context of fever, dry mucous membranes, and skin turgor changes.
B. Hemoglobin levels are crucial for assessing anemia and overall oxygen-carrying capacity of the blood. Although dehydration can potentially concentrate hemoglobin levels, it is not the primary laboratory value to monitor in the context of the acute symptoms
C. The white blood cell count is important for diagnosing infections and understanding the body's response to illness. However, in this scenario, the primary concern is dehydration, which is not directly measured by WBC count. While an elevated WBC could indicate an infection contributing to the fever, it is not the primary laboratory value to monitor for fluid and electrolyte imbalances.
D. Sodium is a key electrolyte that can be significantly affected by dehydration. Dry mucous membranes, inelastic skin turgor, and a fever suggest potential fluid loss and dehydration, which can lead to imbalances in sodium levels. Monitoring sodium levels is crucial because dehydration often results in elevated sodium concentrations (hypernatremia), which can have serious implications for the client’s health.

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Naxlex Comprehensive Predictor Exams

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

Correct Answer is D

Explanation

An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

Correct Answer is D

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

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The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

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A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

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