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Checking for staff with fitted N95 masks before reassigning tasks is time-consuming and unnecessary. Streptococcal pharyngitis spreads via large respiratory droplets, requiring only droplet precautions with a standard surgical mask, gloves, and eye protection. N95 respirators are reserved for airborne pathogens or aerosol-generating procedures, which are not indicated here. This action delays care and misallocates resources, as the UAP can safely respond with standard precautions.

Sending the UAP for immediate N95 fitting is inefficient and unwarranted. The fitting process requires trained personnel and time, delaying patient care. Droplet precautions for streptococcal pharyngitis do not require N95 masks, as the pathogen is not airborne. This action overcomplicates the response, misaligns with CDC guidelines, and diverts focus from the patient’s immediate needs.

Advising the UAP to use a standard mask for vital signs and later get fitted for an N95 for personal care is unnecessarily complex. Droplet precautions with a standard mask are sufficient for all routine interactions with this client. Requiring an N95 for personal care escalates precautions without scientific basis, delays care, and misuses resources.

Auscultating breath sounds after swallowing assesses lung function and aspiration risk but does not directly evaluate the gag reflex. The gag reflex, mediated by cranial nerves IX and X, is tested by stimulating the posterior pharynx. This method is indirect and less specific, as it relies on swallowing, which may not trigger the reflex in a weak client.

Offering small sips of water tests swallowing but not the gag reflex specifically. Swallowing involves multiple cranial nerves, but the gag reflex requires direct stimulation of the posterior pharynx. In a lethargic client, this could risk aspiration, and it does not provide a clear assessment of the reflex needed for safe mouth care.

Using a penlight to observe the oral cavity assesses structure but not function. The gag reflex requires tactile stimulation of the posterior pharynx to elicit a response. Visual inspection cannot confirm the reflex’s presence, which is critical to ensure safety during mouth care in a weak, lethargic client.

Chronic insomnia and atrial fibrillation are not direct risk factors for sleep apnea. Warfarin treats clotting but does not affect airway obstruction. Sleep apnea is linked to obesity and anatomical factors, making this client less likely to require regular nighttime assessments compared to an obese, hypertensive client.

Restless leg syndrome and COPD affect sleep and breathing but are not primary sleep apnea risk factors. COPD causes chronic airflow limitation, not intermittent airway collapse like apnea. Obesity is a stronger predictor, making the obese client with comorbidities a higher priority for regular sleep apnea assessments.

Choice D reason: A bleeding ulcer, high stress, and flurazepam use may disrupt sleep but are not specific to sleep apnea. Flurazepam, a sedative, may worsen undiagnosed apnea by relaxing airway muscles. Obesity remains a stronger risk factor, making the obese client with comorbidities the priority for regular apnea assessments.

Removing the needle before discarding syringes increases the risk of needlestick injury, violating standard precautions. CDC guidelines recommend disposing of needles and syringes as a single unit in a sharps container to prevent exposure to bloodborne pathogens. This action demonstrates a misunderstanding of safe handling and infection control practices.

Wearing gloves to dispose of needles and syringes is cautious but not a core component of standard precautions for home administration. Gloves are secondary to handwashing, which prevents contamination before handling equipment. This action is less critical than hand hygiene, which is universally required to minimize infection risk in medication administration.

Donning a face mask before administering medication is unnecessary for standard precautions unless there is a risk of respiratory droplet transmission, which is not typical for syringe use. This action is irrelevant to preventing bloodborne pathogen exposure, indicating a misunderstanding of the infection control measures required for safe medication administration.

Using firm pressure to pass the tube through the glottis is dangerous, as the glottis leads to the trachea, risking respiratory complications. Gagging indicates possible misplacement or irritation. The correct path is through the esophagus, and forceful insertion could cause trauma or perforation, making this an unsafe and incorrect action.

Giving sips of water during gagging is risky, as it could lead to aspiration, especially in a client with a postoperative ileus. Gagging suggests the tube may be misplaced or causing irritation. This action does not address the cause of gagging and could worsen the client’s condition, making it inappropriate.

Tilting the head backward may open the airway but does not facilitate esophageal tube passage and could misalign the tube toward the trachea. Gagging requires pausing and reassessing, not adjusting head position. This action risks incorrect placement and does not address the immediate issue, making it ineffective.

Comparing health status with defining criteria helps diagnose problems but is less relevant when setting goals. Goal identification focuses on addressing established nursing problems to achieve measurable outcomes. This action is part of assessment, not the primary step in formulating care plan goals, which requires prioritizing existing issues.

Listing immediate nursing actions focuses on interventions, not goal-setting. Goals define desired outcomes, while actions are strategies to achieve them. This approach skips the critical step of establishing priorities and outcomes, risking a fragmented care plan that may not address the client’s holistic needs effectively.

Ensuring all prescribed treatments are initiated addresses physician orders but not nursing-specific goals. Nursing goals focus on patient outcomes based on nursing diagnoses, not just medical treatments. This action is relevant to implementation, not the primary step in identifying care plan goals, which requires nursing judgment.

Observing diarrhea appearance may inform infection severity but is not the priority over infection control. C. difficile spreads through contact with contaminated surfaces or feces. Ensuring the UAP wears a gown prevents transmission, protecting the healthcare environment. This action is secondary to immediate precautionary measures.

Assessing skin integrity is important for long-term care but not urgent in this scenario. C. difficile requires immediate contact precautions to prevent pathogen spread. The UAP’s lack of a gown poses a transmission risk, making gown use the priority to ensure safety before addressing skin concerns.

Hanging the antibiotic is part of treatment but not the first priority. The UAP’s lack of a gown violates contact precautions for C. difficile, risking pathogen spread. Ensuring proper protective equipment takes precedence to maintain a safe environment, followed by administering the antibiotic to treat the infection.

The client’s verbal assurance of continuing reflects motivation but not physiological tolerance. Activity intolerance is measured by objective signs like heart rate and respiratory response. Subjective statements may mask fatigue or distress, making this an unreliable indicator of the client’s ability to safely tolerate progressive ambulation.

Stopping frequently to talk may indicate social engagement or fatigue, not tolerance. Activity intolerance requires objective measures like heart rate or respiratory rate. Frequent stops could mask exertion or weakness, making this an ambiguous and unreliable assessment of the client’s ability to sustain ambulation safely.

Progressing from a shuffling to deliberate gait suggests improved coordination but not necessarily activity tolerance. Gait quality does not directly measure cardiovascular or respiratory response to exertion. Heart rate stability is a more precise indicator of physiological tolerance, critical for assessing safety in clients with activity intolerance.

Determining who brought the coffee is irrelevant to addressing the client’s dietary needs. A clear liquid diet includes black coffee, as it is transparent and easily digested. The priority is ensuring dietary compliance, not investigating staff actions, which does not impact the client’s immediate care or safety.

Consulting the dietician is unnecessary, as black coffee is standard in clear liquid diets per nutritional guidelines. This action delays care and overcomplicates a straightforward issue. The nurse can directly clarify that coffee is allowed without additives, ensuring compliance without external consultation.

Removing the coffee is incorrect, as black coffee is permitted in a clear liquid diet. This action unnecessarily restricts the client’s intake and may cause confusion or dissatisfaction. The nurse should instead educate the client about proper consumption, ensuring dietary adherence while maintaining patient comfort.

Deficient fluid volume is unrelated to 150 ml residual urine, which reflects retention, not dehydration. Residual urine suggests bladder dysfunction, not fluid loss. This nursing problem is inappropriate, as the issue is urinary stasis, which predisposes to infection rather than indicating a systemic fluid deficit.

Urinary incontinence involves involuntary urine leakage, not retention. Residual urine of 150 ml indicates the bladder is not emptying fully, suggesting retention rather than incontinence. This nursing problem is incorrect, as the client’s issue is incomplete voiding, which requires different interventions focused on bladder function.

Imbalanced nutrition is unrelated to residual urine, which is a urological issue. Residual urine reflects bladder dysfunction, not dietary or metabolic problems. This nursing problem is irrelevant, as the priority is addressing urinary retention to prevent complications like infection, not nutritional status.