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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While assessing brain stem reflexes can provide valuable information about the neurological status of the client, it is not the immediate priority when preparing to move a client from bed to a chair. Brain stem reflexes are more relevant for assessing overall neurological function and response to stimuli, but they do not directly inform the safety and readiness of the client for physical activity.
B. Assessing the pupillary response is important for evaluating neurological function and consciousness levels. However, it is not directly related to assessing the client’s readiness to be moved from bed to a chair. Pupillary response does not provide specific information about the client’s hemodynamic stability or immediate readiness for physical activity.
C. Assessing the client’s blood pressure is crucial, especially after a stroke, as the client may be at risk for orthostatic hypotension (a sudden drop in blood pressure when standing up). Checking blood pressure helps ensure that the client is hemodynamically stable and can tolerate the change in position without risking dizziness, fainting, or other complications.
D. Offering the client the opportunity to void before getting out of bed is a practical measure to ensure comfort and avoid accidents. It helps prevent the need for the client to seek the bathroom immediately after being moved to the chair, which could be disorienting or potentially hazardous.
Correct Answer is D
Explanation
A. Using a bag valve mask (BVM) to manually ventilate the client would be considered an extraordinary measure, which conflicts with the client's living will stating no extraordinary measures should be taken.
B. While it's essential to ensure that the client's current wishes are respected, the client is likely unable to communicate effectively due to their condition. If the client were able to express their wishes at this stage, it might be important to confirm, but given the client's living will and the established DNR order, the primary focus should be on adhering to these documents.
C. Reporting the client's status to the healthcare provider is important to ensure that the provider is informed about the client’s current condition and can offer guidance or make necessary adjustments in the care plan. However, if the healthcare provider is already aware of the client's living will and DNR order, this step may be secondary to following the existing orders.
D. Administering supplemental oxygen via a nasal cannula is a palliative measure that can provide comfort without being considered an extraordinary measure. It aligns with the goal of providing symptom relief and comfort care rather than resuscitation or life-extending interventions.
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