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

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.

A. Assist the client with clarifying values about end-of-life care options. B. Ask the client how often episodes of sundowning are experienced. C. Request to have the client lie as still as possible for the assessment. D. Question the client about the frequency of falls in recent months.

Correct Answer is D

Explanation

A. This action pertains more to discussions about advance care planning and end-of-life preferences, which may be important but are not directly related to assessing the client's functional status.

B. Episodes of sundowning are associated with changes in behavior, confusion, and agitation in some individuals with dementia, particularly in the late afternoon or evening. While important to assess in certain contexts, it is not directly related to evaluating the client's physical strength and mobility.

C. Asking the client to lie still does not provide information about their functional status or ability to perform activities of daily living.

D. This is the most appropriate action because it directly addresses the client's reported decreased strength and assesses the impact on their functional ability. Falls are a common consequence of reduced strength and mobility in older adults and can provide valuable information about the client's current physical function and safety.

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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

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

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Correct Answer is D

Explanation

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