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 B
Explanation
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.
Correct Answer is C
Explanation
Choice A reason: Feeding the infant every 4 hours is not a specific instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. However, feeding the infant frequently is important to promote hydration and elimination of bilirubin through urine and stool.
Choice B reason: Performing diaper changes under the light is not a recommended instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to turn off the light and cover the infant's eyes with protective goggles or patches during diaper changes to prevent eye damage or irritation.
Choice C reason: This is the correct answer because repositioning the infant every 2 hours is an essential instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to rotate the infant's position every 2 hours to expose different areas of the skin to the light and prevent pressure ulcers or skin breakdown.
Choice D reason: Covering with a receiving blanket is not an appropriate instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to keep the infant unclothed except for a diaper and eye protection during phototherapy to maximize skin exposure to the light and increase its effectiveness.
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