The practical nurse (PN) is monitoring care activities of an unlicensed assistive personnel (UAP). Which observed behavior(s) by the PN indicate that the UAP needs additional guidance? Select all that apply.
Removes the water pitcher from room of client on fluid restriction.
Uses client's same finger when obtaining a blood drop for glucometer.
Applies disposable gown and mask as part of standard precautions.
Maintains Fowler's position for a client with breathing difficulty.
Positions bed in highest position before leaving all client rooms.
Correct Answer : B,C,E
A. Removes the water pitcher from room of client on fluid restriction:
Correct practice for fluid restriction; no guidance needed.
B. Uses client's same finger when obtaining a blood drop for glucometer:
Repeated use can cause trauma/infection; rotate sites.
C. Applies disposable gown and mask as part of standard precautions:
Standard precautions require PPE only when risk of exposure exists, not routinely.
D. Maintains Fowler's position for a client with breathing difficulty:
Correct practice; supports lung expansion.
E. Positions bed in highest position before leaving all client rooms:
Unsafe; bed should be left in lowest position to prevent falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Consensual pupillary constriction present: This refers to both pupils constricting when light is shone in one eye, not accommodation.
B. Peripheral vision intact: Not related to this assessment; peripheral vision testing uses confrontation method.
C. Nystagmus present with pupillary focus: Nystagmus is involuntary eye movement, unrelated to accommodation response.
D. Pupils reactive to accommodation: This describes normal constriction when focusing on near objects after focusing on distant ones.
Correct Answer is D
Explanation
A. Use of pain medication:
Helps understand management but not primary for history-taking of inflammation.
B. Pattern of inflammation:
More relevant for tracking progress than initial history.
C. Mechanism of injury:
Important if trauma is suspected, but the case describes persistent symptoms.
D. Duration of pain:
Key for determining chronicity and possible underlying cause.
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