The nurse observes an unlicensed assistive personnel (UAP) preparing to provide personal care for a patient who requires contact precautions. The UAP has put on a gown and gloves and has secured the tops of the gloves over the gown sleeves. What action should the nurse take?
Remind the UAP to wash hands frequently while in the room.
Confirm that the gown is tied securely at the neck and waist.
Assist the UAP with the application of a face mask or face shield.
Help the UAP reposition the gown sleeve over the glove edges.
The Correct Answer is B
The correct answer is choice B. Confirm that the gown is tied securely at the neck and waist.
Choice A rationale:
Reminding the UAP to wash hands frequently while in the room is important for infection control, but it is not the immediate priority in this scenario. The UAP has already donned gloves, which are part of the personal protective equipment (PPE) required for contact precautions. Hand hygiene is crucial before and after patient contact and after removing gloves, but ensuring the gown is properly secured takes precedence to prevent contamination.
Choice B rationale:
Confirming that the gown is tied securely at the neck and waist is essential to ensure that the UAP is fully protected from potential contamination. A properly secured gown prevents the UAP’s clothing from coming into contact with the patient or contaminated surfaces, which is critical in maintaining effective contact precautions.
Choice C rationale:
Assisting the UAP with the application of a face mask or face shield is necessary for droplet or airborne precautions, not specifically for contact precautions. Since the scenario involves contact precautions, the focus should be on the gown and gloves.
Choice D rationale:
Helping the UAP reposition the gown sleeve over the glove edges is not necessary because the UAP has already secured the tops of the gloves over the gown sleeves. This method is appropriate as it prevents the sleeves from becoming contaminated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Addiction refers to a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The intricate handwashing ritual that lasts two hours or more described by the client does not indicate substance use or dependency, which are common characteristics of addiction.
Choice B rationale
Compulsion refers to repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The client’s intricate handwashing ritual that lasts two hours or more and their concern about maintaining cleanliness align with the definition of a compulsion.
Choice C rationale
Obsession refers to recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and unwanted. While the client’s concern about maintaining cleanliness could potentially be seen as an obsession, the act of handwashing is a behavior, which aligns more with the definition of a compulsion.
Choice D rationale
Phobia refers to an extreme or irrational fear of or aversion to something. The client’s behavior does not indicate an extreme or irrational fear but rather a compulsion to maintain cleanliness through an intricate handwashing ritual.
Correct Answer is B
Explanation
Choice A rationale
Monitoring leukocytes, neutrophils, and thyroxine is not the most crucial for a patient with end-stage renal disease (ESRD). While these lab values can provide information about the patient’s immune function and thyroid function, they do not directly relate to the patient’s renal function.
Choice B rationale
Monitoring serum potassium, calcium, and phosphorus levels is crucial for a patient with ESRD. These electrolytes are typically excreted by the kidneys, and their levels can become imbalanced in patients with ESRD. Imbalances can lead to serious complications, such as cardiac arrhythmias and bone disease.
Choice C rationale
Monitoring erythrocytes, hemoglobin, and hematocrit is important for a patient with ESRD, as these patients often develop anemia due to decreased erythropoietin production by the kidneys. However, these are not the only lab values that should be monitored in these patients.
Choice D rationale
Monitoring blood pressure, heart rate, and temperature is important for all patients, but these are not specific to patients with ESRD. Patients with ESRD are at risk for electrolyte imbalances, which can affect cardiac function, making monitoring of serum potassium, calcium, and phosphorus levels more crucial.
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