A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

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

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

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 emesis.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Remind the UAP to apply a fitted respirator mask before entering the client's room: A fitted respirator (such as an N95) is required for airborne precautions (e.g., tuberculosis, measles, or varicella). Because Neisseria meningitidis is transmitted via droplets that do not remain suspended in the air, a standard surgical mask is sufficient. Requiring an N95 mask is an unnecessary level of protection for this specific pathogen.

B. Assign the UAP to provide care for another client and assume full care of the client:
Delegating tasks based on infection risk may be reasonable, but it's not necessary to reassign care if the UAP follows proper precautions.

C. Review the need for the UAP to wear a face mask while in close contact with the client: Droplet Precautions require anyone entering the room or coming within 3 to 6 feet of the client to wear a standard surgical mask. The nurse must ensure the UAP understands that because the client is coughing or vomiting (which can aerosolize droplets), a mask is mandatory to prevent transmission. This intervention prioritizes safety through proper education and adherence to infection control protocols.

D. Instruct the UAP to notify the nurse of any changes in the client's emesis: Monitoring emesis is part of ongoing care but is not as urgent as preventing transmission of a highly contagious illness. Infection control measures must be enforced before other instructions.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Encouraging the client to join a support group: While beneficial, referring the client to a support group does not immediately address the client's psychosocial need for acceptance in the nurse-client interaction. Acceptance should first be modeled directly by caregivers.

B. Allowing the client to ventilate feelings: This addresses emotional support but does not necessarily promote acceptance. The client may still feel socially isolated or judged if the nurse maintains physical distance or acts hesitantly.

C. Shaking the client's hand during an introduction: This action demonstrates respect, inclusion, and nonjudgmental care. It helps normalize the interaction and signals to the client that the nurse does not view their skin condition as repulsive or infectious. Such gestures reduce stigma and build trust.

D. Wearing gloves when interviewing the client: Gloving when unnecessary can send a message that the client is contaminated. For non-contact interviews, gloves are not required and may make the client feel rejected or judged. It contradicts acceptance goals.

A. The left radial pulse is 2+ bounding. B. Assessment of a bruit on the left forearm. C. Auscultation of a thrill on the left forearm. D. Distended, tortuous veins in the left hand.

Correct Answer is B

Explanation

Rationale:
A. The left radial pulse is 2+ bounding: A radial pulse reflects arterial blood flow but does not confirm the functionality of the AV fistula. It may be normal even if the fistula is occluded or nonfunctional.

B. Assessment of a bruit on the left forearm: A bruit, a whooshing sound heard with a stethoscope, indicates turbulent blood flow through the AV fistula, confirming that the fistula is patent and functioning. This is a key sign of fistula viability.

C. Auscultation of a thrill on the left forearm: A thrill is felt (palpated), not auscultated. While a thrill is also a sign of patency, the phrasing here is incorrect. The term “auscultation” applies to the bruit, not the thrill.

D. Distended, tortuous veins in the left hand: Prominent hand veins may occur with vascular changes but do not confirm AV fistula patency. Assessment must include direct evaluation for a bruit or thrill over the fistula site.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

Correct Answer is C

Explanation

A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

Correct Answer is B

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

The nurse administers ophthalmic timolol to a client with glaucoma. The client routinely takes carvedilol, spironolactone, and ibuprofen daily. Which medication(s) should the nurse withhold? Select all that apply.

The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants?

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse delegate to the UAP?

A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image)