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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Bulging fontanels are not typically associated with withdrawal from maternal methadone use. They might indicate increased intracranial pressure or other conditions.
B. Correct. Hypertonicity, or increased muscle tone, is a common sign of neonatal withdrawal from opioids such as methadone. It can manifest as increased resistance to passive movement.
C. Incorrect. Bradycardia is not a common withdrawal symptom from maternal methadone use. Neonates withdrawing from opioids might experience tachycardia, not bradycardia.
D. Incorrect. Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to withdrawal from methadone. It can be related to immature peripheral circulation.
Correct Answer is ["B","C","E","F"]
Explanation
A. Attends school regularly: While attending school regularly is important, it is not an immediate concern that requires follow-up compared to the other more pressing issues related to the traumatic event and the client's mental well-being.
B. Caregiver reporting client acting differently than usual: This finding requires immediate follow-up because it indicates a change in the client's behavior and could be indicative of emotional distress or mental health issues, especially considering the recent traumatic event they experienced.
C. Witnessing their family's death: Witnessing the death of family members in a traumatic event like a tornado is a significant and potentially traumatizing experience that requires immediate follow-up and support.
D. Heart rate 99/min: While a heart rate of 99/min is slightly elevated, it is not a critical finding that requires immediate follow-up in this context. The other findings are more relevant to the client's psychological well-being.
E. Smoking marijuana to clear their mind: The client's use of marijuana to cope with their thoughts and feelings should be addressed promptly, as it could indicate maladaptive coping mechanisms or potential substance abuse.
F. Client experiences nightmares: Experiencing nightmares could be a symptom of post-traumatic stress disorder (PTSD) or other mental health concerns related to the traumatic event.
G. BP 122/80 mm Hg: A blood pressure of 122/80 mm Hg is within a normal range and is not a cause for immediate concern.
H. Startles easy during thunderstorm: While startle responses can be related to anxiety, this specific finding is not as pressing as the client's reported coping mechanisms and traumatic experiences.
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