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 C
Explanation
Choice A rationale
Monitoring capillary refill distal to the infusion site is a general nursing intervention during IV therapy. However, it is not specific to the administration of a vesicant chemotherapeutic agent.
Choice B rationale
Applying a topical anesthetic at the infusion site for burning is not a standard intervention during the administration of a vesicant chemotherapeutic agent. The burning sensation is not due to the IV site but due to the vesicant agent itself.
Choice C rationale
Assessing the IV site frequently for signs of extravasation is the most appropriate intervention during the administration of a vesicant chemotherapeutic agent. Extravasation, the leakage of the vesicant into the surrounding tissue, can cause severe local tissue damage. Early detection and intervention are crucial to minimize harm.
Choice D rationale
While it is important to explain potential side effects to the client, explaining that temporary burning at the IV site may occur is not the most crucial intervention. The priority is to monitor for and prevent extravasation.
Correct Answer is D
Explanation
Choice A rationale
While abdominal cramping can be a symptom of gastritis, it is not typically a sign of a serious complication that would require immediate medical attention.
Choice B rationale
Bruising of the skin is not typically associated with gastritis. If the client notices unexplained bruising, they should report it, but it is not the most critical symptom to watch for.
Choice C rationale
A low-grade fever can be a symptom of gastritis, but it is not typically a sign of a serious complication. The client should monitor their temperature, but it is not the most critical symptom to watch for.
Choice D rationale
Bloody emesis can be a sign of a serious complication of gastritis, such as a bleeding ulcer. If the client notices bloody or coffee-ground emesis, they should seek medical attention immediately.
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