The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

Praise the UAP for using standard precautions.

Instruct the UAP to change gloves immediately.

Request that an in-service program be scheduled on asepsis.

Submit an adverse occurrence report to the unit manager.

Answer and Explanation

The Correct Answer is B

Choice A reason: Praising the UAP for using standard precautions is not appropriate in this situation as using the same gloves for multiple clients breaches infection control protocols.

Choice B reason: The nurse should instruct the UAP to change gloves immediately to prevent cross-contamination between clients.

Choice C reason: While scheduling an in-service program on asepsis is beneficial for long-term education, it does not address the immediate risk of infection.

Choice D reason: Submitting an adverse occurrence report may be necessary if there is a pattern of non-compliance, but the first action should be to correct the behavior and ensure client safety.

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Correct Answer is ["C","D"]

Explanation

Choice A rationale: A shuffling gait increases fall risk but does not directly impair ability to perform foot care or toenail trimming, so UAP assignment is not primarily indicated here.

Choice B rationale: Urinary incontinence affects bladder control, not manual dexterity or safety during foot care. It does not necessitate UAP assistance for toenail trimming or routine foot care.

Choice C rationale: Syncope when bending increases risk of fainting during foot care tasks, making independent toenail trimming unsafe. UAP support ensures safety and prevents injury during routine care.

Choice D rationale: Hand tremors impair fine motor control, making toenail trimming difficult and unsafe. UAP assistance is indicated to prevent injury and ensure proper routine foot care.

A. Confirm that bowel sounds are present. B. Measure the client's total body weight. C. Evaluate the client's ability to swallow. D. Observe for signs of fluid volume deficit.

Correct Answer is A

Explanation

Choice A reason: Before initiating tube feeding, it is crucial to ensure that the gastrointestinal system is functioning. The presence of bowel sounds indicates peristalsis, which is necessary for the digestion and absorption of the feeding.

Choice B reason: While measuring the client's total body weight is important for overall assessment and monitoring of nutritional status, it is not the most critical assessment before starting tube feeding.

Choice C reason: Evaluating the client's ability to swallow is not relevant in this scenario since the client will be receiving nutrition through a feeding tube due to malnutrition and dehydration.

Choice D reason: Observing for signs of fluid volume deficit is important, but the immediate concern before starting tube feeding is to confirm gastrointestinal activity through the presence of bowel sounds.

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The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["C","D"]

Explanation

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Correct Answer is A

Explanation

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