An older 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?

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.

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.

Answer and Explanation

The Correct Answer is D

Given the older client's history of heart failure and current diagnosis of influenza, it is important for the nurse to ensure that appropriate infection control measures are being followed while providing care. In this scenario, the nurse observes the UAP wearing a gown and gloves to assist the client with sitting up to eat lunch. The nurse should review the need for the UAP to wear a face mask while in close contact with the client. Influenza is spread through respiratory droplets, so wearing a face mask is an important infection control measure to prevent the spread of the virus.

Reminding the UAP to apply a fitted respirator mask before entering the client's room may not be necessary in this situation, as a regular face mask may be sufficient for preventing the spread of influenza.

Additionally, the nurse should instruct the UAP to notify the nurse of any changes in the client's respiratory status. This will allow the nurse to monitor the client's condition closely and intervene promptly if needed.

Assigning the UAP to provide care for another client and assuming full care of the client may not be necessary, as long as appropriate infection control measures are being followed.

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Correct Answer is D

Explanation

A. Incorrect. Postural drainage is usually performed multiple times a day, usually three to four times, to effectively mobilize respiratory secretions.
B. Incorrect. Percussions are typically performed using cupped hands to create vibrations. Holding the hand flat would not produce the desired effect.
C. Bronchodilator should be administered PRIOR to procedure if prescribed
D. Postural drainage should be performed before meals or at least 1-2 hours after meals to prevent vomiting or aspiration.

A. Sore throat. B. Frequent swallowing. C. Blood-tinged mucus. D. Dark brown emesis.

Correct Answer is B

Explanation

Choice A rationale:

A sore throat is a common and expected finding after a tonsillectomy due to irritation from the procedure. While it can cause discomfort, it is not a priority concern unless it worsens significantly or is accompanied by other symptoms indicating complications such as bleeding or infection.

Choice B rationale:

Frequent swallowing can be a sign of bleeding after a tonsillectomy. The child may swallow more often to clear blood or blood clots from the throat, which could indicate that there is active bleeding from the surgical site.

Choice C rationale:

Blood-tinged mucus is a common finding in the immediate postoperative period after a tonsillectomy. It is expected due to the healing process and is not a cause for concern unless it becomes profuse or is accompanied by active bleeding.

Choice D rationale:

While dark brown vomit may indicate that the child has swallowed blood, it is not as immediately concerning as frequent swallowing, which could suggest active bleeding at the surgical site. Dark brown emesis is typically less alarming, but it should still be monitored closely.

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An older 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

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