A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an unlicensed assistive personnel (UAP) donning a pair of gloves before entering the room to give the child a popsicle. Which action should the nurse take?

Assign the UAP to provide care for another client and assume full care of the client.

Remind the UAP to apply a fitted respirator mask before entering the client's room.

Review the need for the UAP to wear a face mask while in close contact with the client.

Instruct the UAP to notify the nurse of any changes in the client's respiratory status.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assigning the UAP to provide care for another client and assuming full care of the client is not the best action for the nurse to take. This may disrupt the continuity of care and the rapport between the UAP and the client. It may also be unnecessary and inefficient for the nurse to take over the care of the client.

Choice B reason: Reminding the UAP to apply a fitted respirator mask before entering the client's room is not the best action for the nurse to take. This may be incorrect and inappropriate for the prevention of pertussis transmission. A fitted respirator mask is used for airborne precautions, while pertussis is spread by droplet contact.

Choice C reason: Reviewing the need for the UAP to wear a face mask while in close contact with the client is the best action for the nurse to take. This can educate the UAP about the proper infection control measures for pertussis, which include droplet precautions. A face mask can prevent the UAP from inhaling or spreading the droplets that contain the bacteria.

Choice D reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is not the best action for the nurse to take. This may be irrelevant and redundant for the situation. The UAP should already know to report any changes in the client's condition to the nurse, regardless of the diagnosis or the intervention.

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Correct Answer is D

Explanation

Choice A reason: 30 mL of serous fluid from a compression bulb device is not a cause for concern. It indicates that the wound is healing and the device is functioning properly.

Choice B reason: 40 mL per hour of dark, cloudy urine from a urinary catheter may indicate dehydration, infection, or hematuria, but it is not an immediate priority. The nurse should monitor the urine output and characteristics, and report any abnormal findings to the provider.

Choice C reason: 20 mL of serosanguinous drainage from a chest tube is expected after thoracic surgery. It reflects the normal inflammatory response and the removal of excess fluid from the pleural space.

Choice D reason: No observable drainage from a 3-day-old Penrose drain is a sign of possible obstruction or infection. The nurse should assess the site for swelling, redness, pain, or purulent drainage, and notify the provider immediately. The Penrose drain should be replaced or removed as soon as possible.

A. Ensure transfer of the client's electronic chart code. B. Give a detailed report to accepting nurse. C. Give client written information about end-of-life care. D. Take the family to the client's new room.

Correct Answer is B

Explanation

Choice A reason: Ensuring transfer of the client's electronic chart code is a necessary action, but it is not the most important. The nurse should make sure that the client's records are updated and accessible to the palliative care team, but this can be done after the client is settled in the new room.

Choice B reason: Giving a detailed report to the accepting nurse is the most important action, as it ensures continuity and quality of care for the client. The nurse should provide information about the client's diagnosis, prognosis, preferences, goals, medications, interventions, and family situation.

Choice C reason: Giving client written information about end-of-life care is a helpful action, but it is not the most important. The nurse should provide the client with educational materials and resources about palliative care, hospice care, advance directives, and bereavement support, but this can be done later or by the palliative care team.

Choice D reason: Taking the family to the client's new room is a supportive action, but it is not the most important. The nurse should assist the family with the transition and offer emotional support, but this can be done after the report is given to the accepting nurse.

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A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an unlicensed assistive personnel (UAP) donning a pair of gloves before entering the room to give the child a popsicle. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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