An unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment, verbalizing they have not been fitted for a particulate filter mask. Which action should the nurse take?

Before changing assignments, determine which staff members have fitted particulate filter masks.

Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client.

Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client.

Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.

Answer and Explanation

The Correct Answer is D

A.   This action involves assessing which staff members are appropriately equipped to handle the situation. While it is useful to know which staff are fitted with particulate filter masks, this step does not directly address the UAP’s immediate concern or resolve the issue with the current assignment.
B.   Pertussis (whooping cough) is a disease that requires droplet precautions, which generally means using a standard surgical mask rather than a particulate filter mask. However, it’s crucial to ensure that the UAP is aware of and follows the correct infection control measures.
C.   Pertussis requires droplet precautions, which usually involve wearing a standard surgical mask, not a particulate filter mask (N95). Fitting for an N95 mask is generally reserved for airborne precautions.
D.   This action addresses the immediate need by allowing the UAP to perform tasks that do not involve close personal care (such as taking vital signs) with a standard face mask, which is appropriate for droplet precautions. It also ensures that the UAP receives proper fitting for a particulate filter mask if needed for other tasks or future assignments.

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Correct Answer is D

Explanation

A. Hemoglobin (Hgb) and Hematocrit (Hct) are important indicators of anemia, which can be caused by nutritional deficiencies such as iron, vitamin B12, or folate deficiencies. For an older adult female, the reference range for hemoglobin is 12 to 16 g/dL, and the hematocrit range is 37% to 47%. A hemoglobin of 11.8 g/dL and a hematocrit of 34% are below the normal range, indicating potential anemia, which could be related to nutritional deficiencies.
B. Weight loss or being underweight can be a sign of nutritional deficiency, particularly if it is unintentional. However, this option lacks specific details about the extent of weight loss and its relation to other indicators. Weight alone does not provide complete information about nutritional deficiencies without additional context, such as changes in weight over time or body composition.
C. A decrease in lean body mass can be indicative of malnutrition or a prolonged deficiency in protein or overall caloric intake. While it is an important indicator of nutritional status, it reflects long-term changes and may not immediately show acute deficiencies.
D. Serum albumin and serum transferrin are biomarkers of nutritional status. The reference range for serum albumin is 3.5 to 5.0 g/dL, and for serum transferrin, it is 250 to 380 mg/dL. A serum albumin level of 3 g/dL and a serum transferrin level of 180 mg/dL are both below the normal range, indicating possible malnutrition or protein deficiency.

A. An adult client who has a history of sleep apnea and needs help applying a continuous positive airway pressure (CPAP) before bedtime. B. The parent of a child who reports the child cannot sleep because there is too much noise in the hallway. C. An older adult client recently admitted from a long-term care facility who is exhibiting sundowning behaviors. D. An older adult client who is anxious about an impending procedure and is worried about being unable to sleep.

Correct Answer is A

Explanation

A. Sleep apnea is a serious condition where the airway becomes blocked during sleep, which can lead to significant health issues, including heart problems and severe oxygen desaturation. The CPAP machine is crucial for managing sleep apnea by ensuring continuous airflow during sleep. If this client needs help applying the CPAP and does not get the assistance they need, they may experience severe complications from untreated sleep apnea.
B. While noise in the hallway can certainly disrupt a child’s sleep and cause distress, it is not an immediate health crisis. It is important to address environmental concerns for comfort and sleep quality but this situation is less critical compared to the potential health risks associated with untreated sleep apnea.
C. Sundowning refers to increased confusion and agitation in the late afternoon or evening, which can be distressing and challenging to manage. While important, this issue is generally not as immediately life-threatening as problems related to sleep apnea or severe anxiety about a procedure.
D. Anxiety about an upcoming procedure and difficulty sleeping are significant concerns, especially for emotional and mental well-being. However, while this client’s anxiety should be addressed to improve their comfort and preparation for the procedure, it does not present an immediate physical threat to health like the potential complications of untreated sleep apnea.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

Correct Answer is A

Explanation

An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?