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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Heparin in Normal Saline prescribed for deep vein thrombosis is not a safe infusion to administer without an IV infusion pump. Heparin is a high-alert medication that requires precise and consistent dosing and monitoring. An IV infusion pump can ensure accurate and steady delivery of heparin and prevent adverse effects such as bleeding or clotting.
Choice B reason: Regular Insulin in Normal Saline prescribed for ketoacidosis is not a safe infusion to administer without an IV infusion pump. Insulin is a high-alert medication that requires careful and frequent adjustment of the infusion rate based on the blood glucose level. An IV infusion pump can provide precise and flexible control of the insulin infusion and prevent complications such as hypoglycemia or hyperglycemia.
Choice C reason: Magnesium in Normal Saline prescribed for hypomagnesemia is not a safe infusion to administer without an IV infusion pump. Magnesium is a medication that can cause serious side effects such as cardiac arrhythmias, respiratory depression, or neuromuscular weakness if infused too rapidly or in excess. An IV infusion pump can regulate the infusion rate and volume of magnesium and prevent toxicity or overdose.
Choice D reason: Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia is a safe infusion to administer without an IV infusion pump. Ceftriaxone is an antibiotic that can be given as a bolus or a slow infusion over 30 minutes. It does not require frequent or precise adjustment of the infusion rate or volume. It can be administered using a gravity drip method with a manual flow regulator and a drop factor.
Correct Answer is D
Explanation
Choice A reason: The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube is not the most urgent client to check. The client may have some bleeding and inflammation from the surgery, but the condition is not life-threatening or unstable. The client requires routine care and monitoring of the chest tube and the wound.
Choice B reason: The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dL (10.8 mmol/L) is not the most urgent client to check. The client may have improved from the initial presentation of high blood glucose, acidosis, and dehydration, but the condition is not life-threatening or unstable. The client requires education, fluid replacement, and insulin administration.
Choice C reason: The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch is not the most urgent client to check. The client may have some postoperative complications such as infection, obstruction, or leakage, but the condition is not life-threatening or unstable. The client requires observation, comfort measures, and stoma care.
Choice D reason: The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90% is the most urgent client to check. The client has a serious and unstable condition that requires chest tube insertion and oxygen therapy. The client is at risk of respiratory failure, hypoxia, or tension pneumothorax and needs to be assessed and treated as soon as possible.
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