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 ["A","C","E","G","H"]
Explanation
The correct answer is:Choices c, e, g, h, and a.
Choice A rationale (Current medications): The client is taking Ibuprofen 800 mg three times daily as needed for arthritis pain.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation, ulcers, and bleeding, especially when used at high doses or for a prolonged period12. Given the client’s symptoms of abdominal pain and a history of dark, tarry stool, the medication could be contributing to these symptoms and warrants further investigation.
Choice B rationale (Temperature): The client’s temperature is 37.5° C (99.5° F), which is within the normal range34. Therefore, it does not require immediate follow-up.
Choice C rationale (Hemoglobin and hematocrit): The client’s hemoglobin level is 9.1 g/dL, which is lower than the normal range of about 13.0 to 17.5 g/dL for adult males and 12.0 to 15.5 g/dL for adult females56.The client’s hematocrit is 27%, which is also lower than the normal range of about 38.3% to 48.6% for adult males and 35.5% to 44.9% for adult females7.Low hemoglobin and hematocrit levels can indicate anemia, which could explain the client’s reported fatigue and pale mucous membranes87.
Choice D rationale (WBC count): The client’s WBC count is 6,700/mm3, which falls within the normal range of about 4,500 to 11,000 WBCs per microliter910. Therefore, it does not require immediate follow-up.
Choice E rationale (Blood pressure): The client’s blood pressure is 90/50 mm Hg, which is lower than the normal range11. Low blood pressure can cause symptoms such as dizziness, fainting, or blurred vision and requires immediate follow-up.
Choice F rationale (Respiratory rate): The client’s respiratory rate is 18 breaths per minute, which is within the normal range for adults of about 12 to 20 breaths per minute412. Therefore, it does not require immediate follow-up.
Choice G rationale (Stool results): The client’s stool tested positive for blood (Hemoccult positive), which could indicate gastrointestinal bleeding13. This finding, combined with the client’s reported abdominal pain and history of dark, tarry stool, requires immediate follow-up.
Choice H rationale (Heart rate): The client’s heart rate is 118 beats per minute, which is higher than the normal range for adults of about 60 to 100 beats per minute14.A high heart rate, or tachycardia, can be caused by factors such as stress, anxiety, physical exertion, dehydration, and certain medical conditions14. Given the client’s reported symptoms and medical history, this finding warrants immediate follow-up.
Correct Answer is C
Explanation
- A. Incorrect. While it's important to maintain social interaction with the client, avoiding excessive conversation during feeding is recommended. Distractions can interfere with the client's ability to focus on swallowing and increase the risk of aspiration.
- B. Incorrect.Coughing is a natural reflex that helps to clear the airway of any material that may have been aspirated. Discouraging coughing could potentially lead to a more serious problem.
- C. Correct.Sitting at or below the client's eye level provides a clearer view of the food and helps the client maintain control over their swallowing. This can reduce the risk of aspiration.
- D. Incorrect.Lifting the chin can actually increase the risk of aspiration by narrowing the opening to the trachea (windpipe). It's generally recommended to avoid lifting the chin during swallowing.
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