An unlicensed assistive personnel (UAP) who is working on a skilled nursing unit is diagnosed with hepatitis A (HVA). Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, and low-grade fever. Which action should the nurse-manager take next?
Observe the nurse for jaundice and icterus sclera.
Review the immunization status of all unit employees.
Refer the nurse to employee health for serological testing.
Post an employee notice of the outbreak of HVA on the unit.
The Correct Answer is C
Choice A reason: Observing the nurse for jaundice and icterus sclera is not the best action for the nurse-manager to take. These are signs of liver damage that may occur in the later stages of HVA infection. The nurse-manager should not rely on the physical appearance of the nurse to diagnose or rule out HVA. The nurse-manager should also respect the privacy and dignity of the nurse and not make any assumptions based on the skin or eye color.
Choice B reason: Reviewing the immunization status of all unit employees is an important action for the nurse-manager to take, but not the best one. The nurse-manager should ensure that all the staff are vaccinated against HVA or have received immune globulin if exposed. However, this action does not address the immediate needs and concerns of the nurse who is symptomatic and may be infected. The nurse-manager should also consider the possibility of other causes of the nurse's symptoms besides HVA.
Choice C reason: Referring the nurse to employee health for serological testing is the best action for the nurse-manager to take. The nurse-manager should facilitate the prompt and accurate diagnosis and treatment of the nurse who is symptomatic and may have HVA. The nurse-manager should also follow the infection control and reporting protocols of the facility and the health department. The nurse-manager should also provide support and counseling to the nurse and the staff.
Choice D reason: Posting an employee notice of the outbreak of HVA on the unit is not the best action for the nurse-manager to take. The nurse-manager should inform and educate the staff about the risk and prevention of HVA, but not in a way that may cause panic or stigma. The nurse-manager should also protect the confidentiality and rights of the nurse and the UAP who are diagnosed with HVA. The nurse-manager should also consult with the infection control and quality improvement teams before posting any notice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Maintaining in high Fowler's position may help the client breathe easier, but it is not the most important intervention. The client may prefer to lie down or change positions according to their comfort.
Choice B reason: Reporting any change in urine color may indicate dehydration, infection, or kidney problems, but it is not the most important intervention. The client may not have much urine output due to reduced fluid intake and kidney function.
Choice C reason: Keeping mucous membranes moist is the most important intervention, as it can prevent dryness, cracking, and bleeding of the lips, mouth, and throat. The client may have difficulty swallowing and may lose their sense of taste due to the cancer or the treatment. The PN should encourage the family to offer the client sips of water, ice chips, or mouthwash, and to apply lip balm or petroleum jelly.
Choice D reason: Recording the client's daily weight may help monitor the client's nutritional status and fluid balance, but it is not the most important intervention. The client may have significant weight loss due to the cancer or the treatment, and may not want to eat or drink. The PN should respect the client's wishes and not force them to eat or drink.
Correct Answer is B
Explanation
Choice A reason: Contacting the healthcare provider to ensure that a prescription for restraints was written is not the priority action by the nurse-manager. The use of restraints should be avoided as much as possible and only used as a last resort when other alternatives have failed. The nurse-manager should first assess the situation and intervene to protect the client's rights and safety.
Choice B reason: Advising the staff nurse to remove the restraints from the client's wrists is the priority action by the nurse-manager. The use of restraints is a violation of the client's autonomy and dignity and can cause physical and psychological harm. The nurse-manager should educate the staff nurse about the ethical and legal implications of using restraints and the importance of using the least restrictive measures to ensure the client's comfort and safety.
Choice C reason: Determining if the client has an as needed (PRN) prescription for an antianxiety agent is not the priority action by the nurse-manager. The use of medication to sedate the client is also a form of restraint and should be avoided unless absolutely necessary. The nurse-manager should first address the inappropriate use of physical restraints and then explore other non-pharmacological interventions to calm the client.
Choice D reason: Closing the door to the room to avoid disturbing other clients in nearby rooms is not the priority action by the nurse-manager. The use of restraints can increase the risk of injury, infection, and emotional distress for the client. The nurse-manager should not ignore the client's pleas and complaints and should ensure that the client is monitored closely and frequently.
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