The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

Praise the UAP for using standard precautions.

Instruct the UAP to change gloves immediately.

Request that an in-service program be scheduled on asepsis.

Submit an adverse occurrence report to the unit manager.

Answer and Explanation

The Correct Answer is B

Choice A reason: Praising the UAP for using standard precautions is not appropriate in this situation as using the same gloves for multiple clients breaches infection control protocols.

Choice B reason: The nurse should instruct the UAP to change gloves immediately to prevent cross-contamination between clients.

Choice C reason: While scheduling an in-service program on asepsis is beneficial for long-term education, it does not address the immediate risk of infection.

Choice D reason: Submitting an adverse occurrence report may be necessary if there is a pattern of non-compliance, but the first action should be to correct the behavior and ensure client safety.

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Correct Answer is C

Explanation

Choice A reason: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.

Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.

Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.

Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.

A. Drink 800 to 1,000 milliliters of fluid daily. B. Take oxycodone as scheduled to prevent painful bowel movements. C. Add fat-containing foods in the diet to lubricate stools for easier passage. D. Ambulate early and as frequently as possible.

Correct Answer is D

Explanation

Choice A reason: Drinking 800 to 1,000 milliliters of fluid daily is below the recommended intake for most adults, which is generally around 2,000 milliliters per day to help prevent constipation.

Choice B reason: Oxycodone is an opioid that can actually lead to constipation, and its use should be carefully managed, not necessarily taken as scheduled for this purpose.

Choice C reason: Adding fat-containing foods is not a standard recommendation for preventing constipation; instead, a high-fiber diet is usually advised.

Choice D reason: Early and frequent ambulation is encouraged postoperatively to help stimulate bowel function and prevent constipation.

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The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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