A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?
Review the need for the UAP to wear a face mask while in close contact with the client.
Remind the UAP to apply a fitted respirator mask before entering the client’s room.
Assign the UAP to provide care for another client and assume full care of the client.
Instruct the UAP to notify the nurse of any changes in the client’s respiratory status.
The Correct Answer is B
Choice B reason: a fitted respirator mask is required for droplet precautions, which are indicated for clients with influenza. The nurse should remind the UAP to apply a fitted respirator mask before entering the client’s room and ensure that it is worn correctly.
Choice A reason: a face mask is not sufficient for droplet precautions, which are indicated for clients with influenza. A face mask can protect against large droplets, but not against small droplets that can remain in the air and be inhaled.
Choice C reason: assigning the UAP to provide care for another client and assuming full care of the client is not necessary or feasible. The UAP can assist the client with influenza as long as they follow the appropriate infection control measures, such as wearing a fitted respirator mask, gloves, and gown.
Choice D reason: instructing the UAP to notify the nurse of any changes in the client’s respiratory status is not as important as reminding them to apply a fitted respirator mask before entering the client’s room. The UAP should report any changes in the client’s condition, but this does not prevent exposure to influenza.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increasing oxygen to 6 liters/minute is not an intervention that the nurse should implement, as this can worsen the bronchospasm and hypoxia by reducing the hypoxic drive and causing carbon dioxide retention. This is a contraindicated choice.
Choice B reason: Calling for an Ambu resuscitation bag is not an intervention that the nurse should implement, as this is not indicated for a client who is conscious and breathing spontaneously. This is an overreaction choice.
Choice C reason: Instructing the client to lie back in bed is not an intervention that the nurse should implement, as this can increase respiratory distress and compromise airway clearance by reducing lung expansion and increasing abdominal pressure. This is another contraindicated choice.
Choice D reason: Administering a nebulizer treatment is an intervention that the nurse should implement, as this can deliver bronchodilators and anti-inflammatory agents directly to the airways and improve ventilation and oxygenation for this client. Therefore, this is the correct choice.
Correct Answer is C
Explanation
Choice A reason: Measuring urine output daily is not a specific statement for the nurse to include, as this is a general recommendation for all clients with urinary catheters and does not address the potential complications of a suprapubic catheter. This is a distractor choice.
Choice B reason: Observing urine color and clarity is not a relevant statement for the nurse to include, as this does not reflect the condition of the suprapubic catheter or its insertion site. This is another distractor choice.
Choice C reason: Inspecting genital area for signs of infection is an important statement for the nurse to include, as this can help detect and prevent urinary tract infection, peritonitis, or abscess formation, which are common risks associated with suprapubic catheters. Therefore, this is the correct choice.
Choice D reason: Palpating flank area for tenderness is not a necessary statement for the nurse to include, as this is not an accurate or reliable method to assess for kidney function or damage, which are unlikely to occur with a suprapubic catheter. This is another distractor choice.
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