Nokea
A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?
- A. Demonstrate the proper use of personal protective equipment.
- B. Offer to assist the UAP with the collection of the specimen.
- C. Provide the UAP with the infection control policy.
- D. Determine the UAP's knowledge about HIV transmission.
Correct Answer: D
Rationale: Determining the UAP's knowledge about HIV transmission is the first step to address misconceptions and fears, enabling targeted education. Demonstrating PPE, assisting with collection, or providing policy are secondary actions that follow understanding the UAP's knowledge gaps.
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A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control. Play time, parent instruction, and room assignment are secondary.
The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
- A. Notify the healthcare provider.
- B. Monitor for signs of bleeding.
- C. Complete an adverse occurrence report.
- D. Obtain blood for coagulation studies.
Correct Answer: A
Rationale: Notifying the healthcare provider ensures prompt intervention to reverse anticoagulation and prevent bleeding. Monitoring, reporting, and testing are important but follow provider notification.
The nurse manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse manager respond?
- A. Choose to send another nurse who is more receptive because the older nurse is not interested.
- B. Ask the nurse why she thinks there is no need for an in-service program about these emergencies.
- C. Inform the older nurse that in-service is not optional and her scheduled attendance is mandatory.
- D. Encourage the nurse to share her concerns and discuss ways to prepare for such emergencies.
Correct Answer: D
Rationale: Encouraging the nurse to share concerns fosters collaboration and addresses barriers to participation, enhancing engagement. Sending another nurse, questioning her views confrontationally, or mandating attendance may create resentment or fail to address her concerns effectively.
A client with influenza is admitted to the medical unit. The nurse observes an unlicensed assistive personnel (UAP) preparing to enter the client's room to take vital signs and assist with personal care. The UAP has applied gloves and a gown. Which action should the nurse take?
- A. Review the need for the UAP to wear a face mask while in close contact with the client.
- B. Remind the UAP to apply a fitted respirator mask before entering the client's room.
- C. Assign the UAP to provide care for another client and assume full care of the client.
- D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.
Correct Answer: A
Rationale: Reviewing the need for a face mask ensures proper droplet precautions for influenza, completing the UAP's PPE. A respirator is unnecessary, reassigning the UAP is impractical, and monitoring respiratory changes is secondary to infection control.
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
- A. The initial administration of the analgesic.
- B. The decision regarding when to call the healthcare provider.
- C. The documentation of the client's respiratory rate.
- D. The administration of naloxone via IV.
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.