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. St. John's wort is an herbal supplement that can interact with antidepressant medications like amitriptyline and should be avoided.
B. Taking amitriptyline on an empty stomach can lead to gastrointestinal upset, so it is better to take it with food.
C. Amitriptyline can have anticholinergic effects, which might lower blood pressure rather than raise it.
D. Correct. Amitriptyline and other antidepressants take a few weeks to reach their full therapeutic effect, so it's important for the client to understand this delayed response.

A. Monitor progress of task completion with each AP. B. Review the skill level and qualifications of each AP. C. Evaluate the APs' performance of each task. D. Communicate appropriate tasks to the APs with specific expectations

Correct Answer is B,D,A,C

Explanation

Answer:

Review the skill level and qualifications of each AP.
Communicate appropriate tasks to the APs with specific expectations.
Monitor progress of task completion with each AP.
Evaluate the APs' performance of each task.

Explanation:

Review the skill level and qualifications of each AP: Before delegating tasks to the assistive personnel (APs), the nurse should assess their individual skills, training, and qualifications to determine their capabilities. This step ensures that tasks are assigned to the APs who are competent and trained to perform them safely and effectively.
Communicate appropriate tasks to the APs with specific expectations: The nurse should clearly communicate the tasks to be delegated to the APs, providing specific instructions and expectations regarding how each task should be performed. This step helps prevent misunderstandings and ensures that the APs understand what is expected of them.
Monitor progress of task completion with each AP: Once tasks are assigned, the nurse should periodically check on the progress of each AP in completing their assigned tasks. Monitoring helps the nurse ensure that tasks are being performed correctly and in a timely manner.
Evaluate the APs' performance of each task: After the tasks are completed, the nurse should evaluate the performance of each AP. This evaluation involves assessing whether the tasks were performed according to the specific expectations communicated earlier and whether there were any issues or deviations during task completion. The evaluation helps identify areas for improvement and provides feedback for the APs to enhance their skills and performance.

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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

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

Correct Answer is B,D,A,C

Explanation

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