An older adult client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?

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

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.

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

Answer and Explanation

The Correct Answer is A

A. Review the need for the UAP to wear a face mask while in close contact with the client: Influenza is transmitted through respiratory droplets, so the UAP should wear a mask in addition to gown and gloves when assisting the client.

B. Remind the UAP to apply a fitted respirator mask before entering the client's room:
A fitted respirator mask (e.g., N95) is generally used for airborne precautions such as tuberculosis which requires droplet precautions. A face mask is sufficient in this case.

C. Assign the UAP to provide care for another client and assume full care of the client:
While it may be necessary to adjust staffing, this is an extreme response. The UAP can continue caring for the client with proper precautions.

D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status:
While it is always important for the UAP to report changes in the client’s condition, this action does not address the immediate concern about PPE use.

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Correct Answer is D

Explanation

A. If I experience any difficulty with breathing I will report it: Difficulty breathing is a serious side effect of itraconazole, which can cause respiratory issues such as shortness of breath. The client should report this immediately, making this statement appropriate.

B. Drinking grapefruit juice will increase the effects of the medication: Grapefruit juice increases the effects of many medications, including itraconazole, by inhibiting the enzyme responsible for metabolizing the drug.

C. Monitoring for changes in stool color is important: Itraconazole can cause liver toxicity, and monitoring stool color is important as it can indicate liver issues, such as jaundice. The client’s awareness of this potential side effect is appropriate.

D. I should take the medication with antacids: This statement requires correction because antacids can reduce the absorption of itraconazole. The medication should be taken with an acidic drink like cola, not with antacids, to ensure proper absorption.

A. Bring a sterile chest drainage unit from central supply to the unit. B. Observe a client's gait to determine the need for assistance. C. Evaluate a client's urinary catheter for proper drainage. D. Call the pharmacy to obtain a client's next antibiotic dose.

Correct Answer is A

Explanation

A. Bring a sterile chest drainage unit from central supply to the unit: This task can be delegated to a UAP. It involves retrieving an item from central supply, which is a non-clinical task and does not require nursing judgment or clinical assessment.

B. Observe a client's gait to determine the need for assistance: While UAPs can observe and report changes, assessing gait for the need of assistance involves clinical judgment and evaluation of the patient's safety, which should be done by a nurse.

C. Evaluate a client's urinary catheter for proper drainage: Evaluating proper drainage involves clinical assessment, which is within the scope of nursing practice, not a task for a UAP. The nurse should assess for proper functioning and any signs of complications.

D. Call the pharmacy to obtain a client's next antibiotic dose: Calling the pharmacy for medications involves communication and clinical decision-making, which is outside the scope of tasks that can be delegated to a UAP. The nurse should handle medication orders.

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An older adult client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

A client returns to the mental health clinic for assistance with an anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. Which action in the treatment plan should the nurse implement?

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