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 A

Rationale:

A. Remind the UAP to apply a fitted respirator mask before entering the client's room:
Neisseria meningitidis is transmitted via respiratory droplets, and clients require droplet precautions. A fitted respirator mask is necessary when within 3 feet of the client.

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: Education is essential but does not take priority over preventing immediate exposure. Ensuring protective equipment is worn first is more urgent than providing background instruction.

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.

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Free Nursing Study Resources

Correct Answer is ["C","D"]

Explanation

Rationale:
A. Any antianxiety medications: Antianxiety medications are not contraindicated with ophthalmic timolol. Unless they directly impact heart rate or blood pressure significantly, they are generally safe to continue in clients with glaucoma using topical beta blockers.

B. Over-the-counter oral antipyretics: Oral antipyretics like acetaminophen are not known to interact adversely with timolol. These medications can be used safely unless otherwise contraindicated for specific patient conditions like liver disease.

C. Nonsteroidal antiinflammatory drugs: NSAIDs such as ibuprofen, when used long-term with beta blockers like timolol or carvedilol, may blunt the antihypertensive effect and increase renal risk, especially in clients on diuretics like spironolactone. This triple combination increases the chance of nephrotoxicity.

D. Other beta-adrenergic blocker agents: Using timolol with systemic beta blockers like carvedilol increases the risk of bradycardia, hypotension, and heart block. Though timolol is topical, systemic absorption can still occur, requiring caution when combining with other beta-blockers.

E. Oral and subcutaneous anticoagulants: There is no direct contraindication between timolol and anticoagulants. Unless the client has bleeding risks associated with other therapies or conditions, concurrent use is generally acceptable.

A. Initiate use of the bed alarm B. Place all client belongings out of reach C. Instruct the client to call before getting up D. Provide a call button kept within reach E. Place the client in a room near the elevator F. Complete a swallow study before giving anything by mouth

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Rationale:

Initiate use of the bed alarm: This alerts staff when the client attempts to get out of bed, enabling quick assistance. It is especially crucial for clients with unilateral weakness and impaired mobility after stroke. Early response helps prevent falls and related injuries.
Place all client belongings out of reach: Placing items out of reach encourages the client to stretch, reach, or attempt to get out of bed unsafely. Stroke patients may have limited strength and poor balance, making this dangerous. It increases the risk of injury and delays access to essential items.
Instruct the client to call before getting up: Teaching the client to seek assistance before attempting to ambulate minimizes the risk of unassisted movement. Stroke patients often have impaired coordination or weakness, increasing the risk of falling.
Provide a call button kept within reach: Keeping the call bell within the client’s reach promotes autonomy and timely communication with the care team. It enables the client to signal for help easily in case of urgent needs or sudden symptoms.
Place the client in a room near the elevator: A room near the elevator may expose the client to high traffic, noise, and stimulation, which can increase confusion or anxiety. For a stroke patient needing rest and monitoring, this environment is not ideal.
Complete a swallow study before giving anything by mouth: A bedside swallow evaluation identifies risk for aspiration, which is common in stroke clients with impaired speech and facial droop. Preventing oral intake until clearance protects against aspiration pneumonia and choking.

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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 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.

Correct Answer is ["C","D"]

Explanation

Patient Data Exhibits The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Click to indicate which interventions promote client safety. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

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