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.

Answer and Explanation

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.

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Correct Answer is ["B","D","E"]

Explanation

Choice A reason: This is incorrect because providing a diet low in phosphorus is not indicated for a client with cirrhosis of the liver. Phosphorus restriction is more relevant for clients with renal failure, not liver failure.

Choice B reason: This is correct because noting signs of swelling and edema is an essential intervention for a client with cirrhosis of the liver. Swelling and edema are signs of fluid retention and portal hypertension, which are common complications of liver disease.

Choice C reason: This is incorrect because increasing oral fluid intake to 1,500 mL daily is not advisable for a client with cirrhosis of the liver. Fluid restriction may be necessary to prevent fluid overload and ascites, which are common complications of liver disease.

Choice D reason: This is correct because monitoring abdominal girth is an important intervention for a client with cirrhosis of the liver. Abdominal girth measurement can indicate the presence and severity of ascites, which is a common complication of liver disease.

Choice E reason: This is correct because reporting serum albumin and globulin levels is a vital intervention for a client with cirrhosis of the liver. Serum albumin and globulin levels can reflect the liver's synthetic function and indicate the extent of liver damage.

A. Inspect feet every month for ingrown nails, cuts, and calluses. B. Arrange diet schedule around three regular meals a day. C. Get an eye examination with an ophthalmologist annually. D. Using salt, herbs, and spices will improve the flavor of foods.

Correct Answer is C

Explanation

Choice A reason: Inspecting feet every month for ingrown nails, cuts, and calluses is not a statement that indicates understanding, as this is not frequent enough for a client with diabetes who may have impaired sensation and circulation in their feet. The recommended frequency is daily or at least weekly. This is an incorrect choice.

Choice B reason: Arranging diet schedule around three regular meals a day is not a statement that indicates understanding, as this may not be adequate for a client with diabetes who needs to balance their carbohydrate intake and blood glucose levels throughout the day. The recommended schedule is to have smaller and more frequent meals and snacks. This is another incorrect choice.

Choice C reason: Getting an eye examination with an ophthalmologist annually is a statement that indicates understanding, as this can help detect and prevent diabetic retinopathy, which can cause vision loss and blindness. Therefore, this is the correct choice.

Choice D reason: Using salt, herbs, and spices will improve the flavor of foods is not a statement that indicates understanding, as this may not be healthy for a client with diabetes who needs to limit their sodium intake and avoid potential interactions between herbs and medications. The recommended strategy is to use low-sodium seasonings and natural flavors. This is another incorrect choice.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?

Correct Answer is C

Explanation

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?

After receiving report, the nurse can most safely plan to assess which client last?

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statementby the client indicates understanding?

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns on both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?