An unlicensed assistive personnel (UAP) removes isolation attire before leaving the room of a client who requires droplet precautions. Which action should the PN take?

Instruct the UAP in correct removal of contaminated gloves.

Remind the UAP to remove the gown before removing gloves.

Advise the UAP to remove the mask after exiting the room.

Confirm that the UAP has correctly handled the isolation attire.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Instructing the UAP in the correct removal of contaminated gloves focuses only on one aspect of the PPE removal process. While it is important to remove gloves correctly to prevent contamination, this choice does not address the comprehensive handling of all isolation attire. Proper PPE removal involves multiple steps, including the removal of gowns, masks, and gloves in a specific order to minimize the risk of contamination.

Choice B reason:

Reminding the UAP to remove the gown before removing gloves addresses part of the PPE removal process but not the entire procedure. The correct sequence for removing PPE is crucial to prevent self-contamination. However, this choice does not ensure that all steps are followed correctly. The PN needs to confirm that the UAP understands and correctly performs the entire process, not just one step.

Choice C reason:

Advising the UAP to remove the mask after exiting the room is incorrect because masks should be removed before leaving the isolation room to prevent contamination of the environment outside the isolation area. Droplet precautions require that masks be removed inside the room to contain any infectious agents within the isolation area. This choice could lead to the spread of infection if not followed correctly.

Choice D reason:

Confirming that the UAP has correctly handled the isolation attire ensures that all steps in the PPE removal process are followed correctly. This comprehensive approach helps maintain infection control standards and prevents the spread of infectious agents. By verifying that the UAP has correctly removed and disposed of all PPE, the PN ensures that the UAP adheres to proper protocols, thereby protecting both the healthcare workers and other clients.

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Correct Answer is D

Explanation

While caring for a client with Guillain-Barre syndrome, the practical nurse (PN) should report the finding of irregular heart rate to the charge nurse. Guillain-Barre syndrome is a neurological disorder that can affect multiple body systems, including the autonomic nervous system.

Autonomic dysfunction can lead to various cardiovascular abnormalities, such as changes in heart rate and rhythm.

However, irregular heart rate can indicate potential cardiac involvement or autonomic instability, which requires prompt evaluation and intervention. Therefore, the PN should report the finding of an irregular heart rate to the charge nurse for further assessment and appropriate management.

Incorrect:

A, B- Full facial flushing and profuse diaphoresis are common symptoms that can occur in Guillain-Barre syndrome due to autonomic dysfunction. While these findings should be noted and monitored, they may not require immediate reporting unless they are severe or accompanied by other concerning symptoms.

C- Lower leg weakness is a characteristic symptom of Guillain-Barre syndrome and is expected in this condition. The PN should document and monitor the extent and progression of weakness but does not necessarily need to report it unless there are significant changes or complications.

Correct Answer is ["500"]

Explanation

1 liter is equal to 1000 milliliters. Therefore, to calculate the fluid intake in mL, we can multiply 1/2 liter by 1000 mL/liter:

1/2 liter * 1000 mL/liter = 500 mL

So, the practical nurse should document 500 mL as the client's fluid intake.

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An unlicensed assistive personnel (UAP) removes isolation attire before leaving the room of a client who requires droplet precautions. Which action should the PN take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse?

Correct Answer is D

Explanation

A client reports that she ingested 1/2 of a liter of a prep solution for a colonoscopy. How many mL of fluid intake should the practical nurse (PN) document? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["500"]

Explanation

An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?

The practical nurse (PN) receives shift reports for four newborns in the full-term newborn nursery. Which infant should the PN assess first?

The practical nurse (PN) is assisting the recreational director of a long-term care facility in planning outdoor activities for wheelchair-bound older residents who are mentally alert. Which activity should the PN suggest that meets the physical and social needs of these residents?

The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.)

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

The practical nurse (PN) hears an older resident of a long-term care facility shout profanities at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take?