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 ["A","E"]
Explanation
Choice A reason: Consuming foods with saturated fats is not a healthy lifestyle change for a client with coronary artery disease, as this can increase the level of cholesterol and triglycerides in the blood, which can lead to plaque formation and narrowing of the arteries. Therefore, this statement indicates that the client needs additional education.
Choice B reason: Walking 30 minutes per day is a beneficial lifestyle change for a client with coronary artery disease, as this can improve the blood circulation, lower the blood pressure, and reduce the risk of heart attack and stroke. Therefore, this statement does not indicate that the client needs additional education.
Choice C reason: Using a salt substitute is a helpful lifestyle change for a client with coronary artery disease, as this can reduce the sodium intake, which can lower the blood pressure and prevent fluid retention. Therefore, this statement does not indicate that the client needs additional education.
Choice D reason: Keeping a food diary is a useful lifestyle change for a client with coronary artery disease, as this can help the client monitor their calorie intake, portion size, and nutritional quality of their food. This can also help the client identify and avoid unhealthy food choices. Therefore, this statement does not indicate that the client needs additional education.
Choice E reason: Eating more canned vegetables is not a good lifestyle change for a client with coronary artery disease, as canned vegetables often contain high amounts of sodium, which can raise the blood pressure and worsen the condition. Therefore, this statement indicates that the client needs additional education.
Choice F reason: Including oatmeal for breakfast is an advantageous lifestyle change for a client with coronary artery disease, as oatmeal contains soluble fiber, which can lower the cholesterol level and prevent plaque formation in the arteries. Therefore, this statement does not indicate that the client needs additional education.
Correct Answer is B
Explanation
Choice A reason: Remove the catheter and palpate the client’s bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.
Choice B reason: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.
Choice C reason: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.
Choice D reason: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.
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