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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Wearing an N95 respiratory mask is not typically required for routine care of a toddler with respiratory syncytial virus unless performing procedures that generate aerosols.
B. Negative pressure rooms are generally reserved for patients with airborne infections like tuberculosis; respiratory syncytial virus does not typically require isolation in a negative pressure room.
C. Using a designated stethoscope helps prevent the spread of infection to other patients by avoiding cross-contamination.
D. Removing the disposable gown after leaving the toddler's room is appropriate for maintaining infection control but is not specific to caring for a toddler with respiratory syncytial virus.
Correct Answer is B
Explanation
A. Lymphangitis is characterized by inflammation of the lymphatic vessels and is often associated with red streaks and tenderness. The absence of inflammation and tenderness suggests a different etiology.
B. Malignancy is suggested by the presence of a large, nontender, hardened lymph node. These characteristics are commonly associated with metastatic spread of cancer to the lymph nodes. Further diagnostic testing, such as biopsy, would be warranted to confirm malignancy.
C. Viral infection may cause lymphadenopathy, but typically, the lymph nodes are tender and may be enlarged but not necessarily hardened. The absence of tenderness and the hardened consistency of the lymph node suggest a different etiology.
D. Bacterial infection can cause lymphadenopathy, which may be tender and enlarged, but the nontender, hardened nature of the lymph node in this case is more indicative of malignancy
rather than a bacterial infection.
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