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 A
Explanation
A. Give 4 oz (120 mL) of apple juice:
Diaphoresis, confusion, and “not feeling right” indicate hypoglycemia. Rapid-acting carbohydrates should be given immediately if the client can swallow.
B. Administer glucagon 0.5 mg IM:
Used if the client is unconscious or unable to swallow safely.
C. Assess temperature:
Does not address the immediate risk of hypoglycemia.
D. Evaluate deep tendon reflexes:
Not relevant to urgent management of suspected hypoglycemia.
Correct Answer is A
Explanation
A. Continue to auscultate the abdomen for a longer time period: Absence of bowel sounds should be confirmed after listening for 5 minutes in each quadrant before reporting.
B. Determine if client needs to empty bladder: Not related to bowel sounds.
C. Ask client to flex knees to relax the abdomen.: May relax abdomen but does not confirm bowel activity.
D. Notify charge nurse of the absence of bowel sounds: Only after confirming prolonged absence.
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