A caregiver brings a client with end-stage Alzheimer’s disease to the clinic for an appointment with the healthcare provider.

The caregiver confides in the nurse about experiencing sleepless nights and frequent bouts of crying.

What action should the nurse take?

Choice A rationale
Testing the fluid on the dressing for glucose is the immediate action the nurse should take. Clear fluid could be cerebrospinal fluid (CSF), which is often released following spinal surgery. CSF contains glucose, so a positive glucose test would confirm it is CSF.
Choice B rationale
Replacing the dressing using a compression bandage is not the immediate action the nurse should take. While it is important to manage the drainage and prevent infection, the nurse first needs to identify what the clear fluid is.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate action the nurse should take. While this can be part of ongoing wound care and monitoring, the nurse first needs to identify what the clear fluid is.

Choice D rationale
Documenting the findings in the electronic medical record is an important step, but it should not be the immediate action. The nurse first needs to identify what the clear fluid is, as it could indicate a complication from the surgery.

Choice A rationale

The unlicensed assistive personnel (UAP) is providing care to a client with influenza, a respiratory illness that can be transmitted through droplets when the client coughs or sneezes. Therefore, it is crucial for the UAP to wear a face mask while in close contact with the client to prevent the transmission of the virus. This is in line with the standard precautions for infection control, which recommend the use of personal protective equipment (PPE) such as gloves, gowns, and masks when providing care to clients with infectious diseases.
Choice B rationale
Reassigning the UAP to another client and assuming full care of the client is not the most appropriate action in this situation. While it is the nurse’s responsibility to ensure that the UAP is competent and understands the care needs of the client, it is not necessary to reassign the UAP unless there are specific concerns about their ability to provide safe and effective care.
Choice C rationale
While it is important for the UAP to alert the nurse of any changes in the client’s respiratory status, this is not the most immediate action that the nurse should take in this situation. The priority is to ensure that the UAP is wearing appropriate PPE to prevent the transmission of influenza.
Choice D rationale
A fitted respirator mask is typically used when caring for clients with airborne diseases, such as tuberculosis. Influenza is primarily spread through droplets, so a regular face mask is usually sufficient for protection.