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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

While seizure precautions are important for clients receiving certain medications or with certain conditions, they are not typically necessary for clients receiving dopamine. Dopamine, an adrenergic agonist, does not typically increase the risk of seizures.

Choice B rationale

Assessing pupillary response to light hourly is not typically necessary for clients receiving dopamine. Dopamine does not typically affect pupillary response.

Choice C rationale

Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine at low to moderate doses can dilate renal blood vessels, which can increase urine output. Therefore, monitoring urinary output can help assess the effectiveness of the medication and the client’s renal perfusion.

Choice D rationale

While it is important to monitor electrolyte levels in clients receiving certain medications, frequent monitoring of serum potassium is not typically necessary for clients receiving dopamine. Dopamine does not typically affect serum potassium levels.

A. Allowing the client to express their feelings. B. Wearing gloves during the client interview. C. Offering a handshake during introductions. D. Encouraging the client to join a support group.

Correct Answer is C

Explanation

Choice A rationale
Allowing the client to express their feelings is an important part of providing psychosocial support. However, it does not specifically address the client’s need for acceptance.
Choice B rationale

Wearing gloves during the client interview can actually reinforce feelings of stigma and rejection, as it may suggest that the nurse is afraid of touching the client or catching their condition.
Choice C rationale
Offering a handshake during introductions can be a powerful gesture of acceptance, especially for a client with a visible skin condition like psoriasis. It communicates that the nurse is not afraid of physical contact and accepts the client as they are.
Choice D rationale
Encouraging the client to join a support group can provide them with a sense of community and shared experience, but it does not specifically address the client’s need for acceptance in their individual interactions with healthcare providers.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is C

Explanation

In the context of caring for a client diagnosed with psoriasis, which action by the nurse would address the client’s psychosocial need for acceptance?

Correct Answer is C

Explanation

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective?

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?

The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility. Which outcome statement should the nurse include in the plan of care?

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? Select all that apply.

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?