A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning
gloves and a gown to assist the client. Which action should the nurse take?
Remind the UAP to apply a fitted respirator mask before entering the client's room.
Instruct the UAP to notify the nurse of any changes in the client's respiratory status.
Review the need for the UAP to wear a face mask while in close contact with the client.
Assign the UAP to provide care for another client and assume full care of the client.
The Correct Answer is C
Choice A reason: Reminding the UAP to apply a fitted respirator mask before entering the client's room is not a necessary action for the nurse to take. A respirator mask is a type of personal protective equipment (PPE. that filters out airborne particles and droplets that may contain infectious agents. A respirator mask is required for clients who have or are suspected of having airborne diseases, such as tuberculosis, measles, or chickenpox. Influenza is a respiratory disease that is transmitted by droplet contact, not by airborne contact.
Choice B reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is not a specific action for the nurse to take. Respiratory status is an assessment of the client's breathing pattern, rate, depth, effort, and oxygen saturation. Respiratory status can be affected by various factors, such as infection, inflammation, obstruction, or injury. The nurse should monitor the client's respiratory status regularly and teach the UAP to report any signs or symptoms of respiratory distress, such as dyspnea, cyanosis, wheezes, or cough.
Choice D reason: Assigning the UAP to provide care for another client and assuming full care of the client is not a feasible action for the nurse to take. The nurse should delegate tasks according to the scope of practice, competency, and availability of staff. The nurse should not reassign staff without a valid reason or without consulting with other team members. The nurse should also not assume full care of a client unless it is necessary or appropriate. The nurse should supervise and evaluate the UAP's performance and provide feedback and guidance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: 18%. This is not the correct percentage, as it only accounts for one lower extremity. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 18% x 2 = 36%.
Choice B: 27%. This is not the correct percentage, as it only accounts for one and a half lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so one and a half lower extremities would account for 9% x 3 = 27%.
Choice C: 36%. This is the correct percentage, as it accounts for both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 9% x 4 = 36%.
Choice D: 45%. This is not the correct percentage, as it accounts for more than both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so more than both lower extremities would account for more than 9% x 4 = 36%.
Correct Answer is C
Explanation
Choice A: Yellow-tinged sputum is not a critical finding for the nurse to report, as this is a common sign of pneumonia and does not indicate an adverse reaction to meropenem. This is a distractor choice.
Choice B: Nausea and headache are not urgent findings for the nurse to report, as these are mild side effects of meropenem and can be managed with supportive measures. This is another distractor choice.
Choice C: Watery diarrhea is an important finding for the nurse to report, as this can indicate a serious complication of meropenem, such as Clostridioides difficile infection, which can cause severe dehydration, electrolyte imbalance, and sepsis. Therefore, this is the correct choice.
Choice D: Increased fatigue is not a significant finding for the nurse to report, as this can be related to the client's underlying condition and does not suggest a problem with meropenem. This is another distractor choice.
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