The nurse is assigned to care for two critical care clients. One client was admitted yesterday with pneumonia, is being mechanically ventilated and has an elevated temperature. The other client had a thoracotomy two days ago and is now complaining of incisional pain. Which intervention should the nurse implement first?

Assess level of consciousness and vital signs for both clients.

Administered pain medication to the client with incisional discomfort.

Complete a head-to-toe physical assessment for the client with pneumonia.

Review the plan of care and the medications for both clients.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Assess level of consciousness and vital signs for both clients: This action prioritizes airway, breathing, and circulation (ABCs) and ensures prompt identification of any deterioration in either client's condition. It provides critical data needed to safely proceed with further interventions such as administering medications or conducting full assessments.

B. Administered pain medication to the client with incisional discomfort: While pain management is important, it is not the priority over initial assessment of both clients' status—especially the one on mechanical ventilation with an elevated temperature.

C. Complete a head-to-toe physical assessment for the client with pneumonia: A full assessment is essential, but it is not the most immediate action. Checking vital signs and neurological status first can quickly reveal urgent issues that might require rapid intervention.

D. Review the plan of care and the medications for both clients: This is necessary but should be done after determining the clients’ current conditions. Immediate physiological assessment takes precedence in critical care settings to prevent delays in interventions.

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Correct Answer is C

Explanation

Rationale:

A. Remind the UAP to apply a fitted respirator mask before entering the client's room:A fitted respirator (such as an N95) is required for airborne precautions (e.g., tuberculosis, measles, or varicella). Because Neisseria meningitidis is transmitted via droplets that do not remain suspended in the air, a standard surgical mask is sufficient. Requiring an N95 mask is an unnecessary level of protection for this specific pathogen.

B. Assign the UAP to provide care for another client and assume full care of the client:
Delegating tasks based on infection risk may be reasonable, but it's not necessary to reassign care if the UAP follows proper precautions.

C. Review the need for the UAP to wear a face mask while in close contact with the client: Droplet Precautions require anyone entering the room or coming within 3 to 6 feet of the client to wear a standard surgical mask. The nurse must ensure the UAP understands that because the client is coughing or vomiting (which can aerosolize droplets), a mask is mandatory to prevent transmission. This intervention prioritizes safety through proper education and adherence to infection control protocols.

D. Instruct the UAP to notify the nurse of any changes in the client's emesis: Monitoring emesis is part of ongoing care but is not as urgent as preventing transmission of a highly contagious illness. Infection control measures must be enforced before other instructions.

A. Go to the emergency department and complete assigned tasks. B. Shut all doors to client rooms on the unit in case a fire erupts. C. Tell all their assigned clients to stay in their rooms. D. Offer to assist in the intensive care unit with clients ventilator-dependent.

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.

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Naxlex Comprehensive Predictor Exams

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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