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 B

Explanation

A. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.

B. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.

C. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.

D. G (Gravida): This refers to the total number of pregnancies, including the current pregnancy. Since the client is currently pregnant, and she has had three previous pregnancies and one of which was a spontaneous abortion, the total is 5 (1 current pregnancy + 3 previous births + 1 spontaneous abortion). T (Term births): The client has had two full-term births (one at 38 weeks and one at 41 weeks), so T = 2. P (Preterm births): The client has had one preterm birth (at 35 weeks), so P = 1. A (Abortions/miscarriages): The client had one spontaneous abortion at 10 weeks, so A = 1. L (Living children): The client has four living children, so L = 4.

A. Client exhibits a frequent productive cough. B. Client reports using the incentive spirometer every hour while awake. C. Client's breath sounds are clear to auscultation bilaterally. D. Client demonstrates proper use of an incentive spirometer.

Correct Answer is C

Explanation

A. Client exhibits a frequent productive cough: While a productive cough may indicate airway clearance, it does not assess the effectiveness of the incentive spirometer. The primary goal of the incentive spirometer is to improve lung expansion, not to stimulate coughing.

B. Client reports using the incentive spirometer every hour while awake: Regular use of the incentive spirometer is important, but it alone does not fully evaluate its effectiveness. The goal is to improve lung function, and a physical assessment is needed to gauge this.

C. Client's breath sounds are clear to auscultation bilaterally: This is the best indicator of the effectiveness of the incentive spirometer. Clear breath sounds suggest improved lung expansion and ventilation, which is the primary goal of using the device.

D. Client demonstrates proper use of an incentive spirometer: While proper technique is essential for effectiveness, demonstrating correct use does not fully assess whether the desired outcomes are achieved.

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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

Correct Answer is B

Explanation

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is C

Explanation

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