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 A

Explanation

Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.

Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.

A. Every 1 hour for 2 hours. B. Every 5 minutes for one hour. C. Every 15 minutes for one hour, then every 1 hour for 2 hours. D. Every 5 minutes for 30 minutes, then every 4 hours thereafter.

Correct Answer is C

Explanation

Choice A rationale
Monitoring the patient’s blood pressure every 1 hour for 2 hours after paracentesis may not be sufficient. Paracentesis is a procedure to remove fluid that has accumulated in the abdominal cavity (a condition called ascites). This is a common problem in people with certain diseases, including liver and kidney disease. Changes in blood pressure can occur rapidly after this procedure, so more frequent monitoring is needed immediately after the procedure.
Choice B rationale
Monitoring the patient’s blood pressure every 5 minutes for one hour after paracentesis may be too frequent and could cause unnecessary stress for the patient. It is important to balance the need for monitoring with the patient’s comfort and well-being.
Choice C rationale
Monitoring the patient’s blood pressure every 15 minutes for one hour, then every 1 hour for 2 hours after paracentesis is a good schedule. This allows for close monitoring immediately after the procedure, when complications are most likely to occur. It then allows for continued monitoring as the patient stabilizes.
Choice D rationale
Monitoring the patient’s blood pressure every 5 minutes for 30 minutes, then every 4 hours thereafter may not provide enough monitoring in the immediate post-procedure period. While it is important to continue monitoring, the first few hours after the procedure are a critical time when complications are most likely to occur.

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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

Correct Answer is A

Explanation

A patient with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. What schedule should the nurse follow to monitor the patient’s blood pressure after this procedure?

Correct Answer is C

Explanation

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