The nurse assigns an unlicensed assistive personnel (UAP) to a client who has been placed on droplet precautions for a respiratory infection. The UAP requests a change in assignment, stating she has not yet 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 to be able to provide care for the assigned client.

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

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

Answer and Explanation

The Correct Answer is B

Rationale:

A. Before changing assignments, determine which staff members have fitted particulate filter masks: This option suggests rearranging assignments based on respirator fit, but a particulate filter mask (like an N95) is not required for droplet precautions. The focus should be on educating the UAP rather than altering assignments unnecessarily.

B. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client: Droplet precautions require a standard surgical mask, not a particulate filter mask. The nurse should clarify this with the UAP to ensure proper precautions are followed without unnecessary changes or delays in care.

C. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care: This adds unnecessary steps. For droplet precautions, a surgical mask is sufficient for all aspects of client care. There's no need to delay care or obtain a filter mask fitting.

D. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client: This is not necessary for droplet precautions, as it reflects confusion with airborne precautions (e.g., for tuberculosis). The nurse should correct the misunderstanding rather than escalate it.

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Correct Answer is C

Explanation

Rationale:

A. Go to the emergency department and complete assigned tasks: UAPs should remain on their assigned units unless directed otherwise by leadership. Relocating without orders could compromise continuity and safety in their current area.

B. Shut all doors to client rooms on the unit in case a fire erupts: There is no immediate threat of fire. This may increase client anxiety or hinder necessary observation in a power outage. Fire protocols are separate from internal disaster procedures unless a fire is confirmed.

C. Tell all their assigned clients to stay in their rooms: This maintains order and safety during a chaotic event. It prevents unnecessary movement in darkened or unfamiliar areas and reduces the risk of injury in the absence of full power.

D. Offer to assist in the intensive care unit with clients ventilator-dependent: UAPs are not qualified to assist with critical care clients, especially ventilator-dependent ones. They should remain within their competency and scope of practice.

A. A B. B C. C D. D

Correct Answer is B

Explanation

Rationale:

A: This shows the IV insertion site on the hand. While important for checking infiltration or phlebitis, it does not affect flow rate or volume delivered, so it's not the priority in fluid overload.

B: This shows the IV drip chamber. This is the first place to assess because it allows the nurse to determine how fast the IV fluid is infusing. It provides a quick visual cue of the actual flow rate, which is essential in evaluating whether the infusion is too fast, the likely cause of the overload.

C: This is the IV tubing near the insertion site. Kinks or dislodgement can affect flow, but it’s not the most immediate concern when fluid overload is suspected.

D: Shows the roller clamp, this directly controls the flow rate in a gravity system, so it is the place to intervene when fluid overload is suspected. After assessing the flow rate in the drip chamber and confirming fast infusion, the nurse should adjust the flow rate at this part.

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The nurse assigns an unlicensed assistive personnel (UAP) to a client who has been placed on droplet precautions for a respiratory infection. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client is receiving IV fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first?

Correct Answer is B

Explanation

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