The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. Which action should the nurse take?

Confirm that the gown is tied securely at the neck and waist.

Help the UAP reposition the gown sleeve over the glove edges.

Remind the UAP to wash hands frequently while in the room.

Assist the UAP with the application of a face mask or face shield.

None

Answer and Explanation

The Correct Answer is A

A. Confirming that the gown is tied securely at the neck and waist is correct. Properly securing the gown ensures full coverage and prevents gaps where contamination could occur. This step is crucial for maintaining effective contact precautions.
B. Helping the UAP reposition the gown sleeve over the glove edges is incorrect. Standard PPE protocol requires that gloves be worn over the gown sleeves to prevent exposure when the hands are raised or moved.
C. Reminding the UAP to wash hands frequently while in the room is incorrect. While hand hygiene is always important, ensuring proper PPE use is the immediate priority in this scenario.
D. Assisting the UAP with the application of a face mask or face shield is incorrect. Contact precautions do not require a mask or face shield unless there is a risk of splashes or sprays of infectious material.

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Correct Answer is ["B","C","D"]

Explanation

A. Instruct client and family to reconsider end of life choices.
This is not an appropriate intervention. In hospice care, the focus is on providing comfort and supporting the client’s and family’s current end-of-life choices rather than challenging them.

B. Encourage family to visit frequently.
Encouraging family visits can provide emotional support and comfort to the client, helping them cope with feelings related to death and dying.

C. Teach client how to use guided imagery.
Guided imagery can be a helpful technique for managing anxiety and emotional distress, offering the client a method to find peace and comfort.

D. Encourage family to bring the client old photographs.
Old photographs can help evoke positive memories and provide comfort, aiding the client in coping with feelings of death and dying.

E. Record the client's desire to live.
Recording the client's desires is important for documenting their wishes, but it is not an intervention that directly aids in coping with feelings related to death and dying.

A. Increase in breath sounds. B. Absence of fine crackles. C. Absence of coarse crackles. D. Increase in respiratory rate.

Correct Answer is B

Explanation

A. An increase in breath sounds may suggest improved airflow, but it does not necessarily indicate effective mobilization of secretions.
B. Absence of fine crackles indicates that there are no longer small airway secretions or fluid in the lungs, suggesting that the chest physiotherapy was effective in mobilizing secretions.
C. While the absence of coarse crackles is also a positive finding, fine crackles specifically indicate fluid or secretions in the small airways, making their absence a more direct indicator of the effectiveness of chest physiotherapy.

D. An increase in respiratory rate may indicate respiratory distress or worsening of the condition, rather than effectiveness of the chest physiotherapy in mobilizing secretions.

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The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What intervention(s) should the nurse include in this client's plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective?

Correct Answer is B

Explanation

The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. Which action should the nurse take?

Exhibits The nurse reviews the findings in the history and physical. Select from Word Choices to complete the sentence. The nurse recognizes that dropdown ,dropdown and dropdown are findings consistent with elder mistreatment.

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Exhibits Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

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