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 B
Explanation
Choice A reason: Ensuring transfer of the client's electronic chart code is a necessary action, but it is not the most important. The nurse should make sure that the client's records are updated and accessible to the palliative care team, but this can be done after the client is settled in the new room.
Choice B reason: Giving a detailed report to the accepting nurse is the most important action, as it ensures continuity and quality of care for the client. The nurse should provide information about the client's diagnosis, prognosis, preferences, goals, medications, interventions, and family situation.
Choice C reason: Giving client written information about end-of-life care is a helpful action, but it is not the most important. The nurse should provide the client with educational materials and resources about palliative care, hospice care, advance directives, and bereavement support, but this can be done later or by the palliative care team.
Choice D reason: Taking the family to the client's new room is a supportive action, but it is not the most important. The nurse should assist the family with the transition and offer emotional support, but this can be done after the report is given to the accepting nurse.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.