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An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.
- B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client.
- C. Before changing assignments, determine which staff members have fitted particulate filter masks.
- D. Send the UAP to be fitted for a particulate filter mask immediately to be able to provide care to this client.
Correct Answer: B
Rationale: Standard mask suffices for droplet precautions.
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The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. Is there any particular reason why you think this is your fault?
- B. With surgery, your baby should have a full recovery.
- C. This must be a very difficult time for you.
- D. You did nothing wrong.
Correct Answer: C
Rationale: Empathy validates emotional distress.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
- A. Offer positive reinforcement.
- B. Provide physical demonstrations.
- C. Use simulation activities.
- D. Incorporate verbal analogies.
Correct Answer: C
Rationale: Simulations enhance problem-solving skills.
The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?
- A. Analogies.
- B. Role-playing.
- C. Return demonstration.
- D. Journaling.
Correct Answer: B
Rationale: Role-playing builds communication skills.
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Stethoscope.
- B. Bed linens.
- C. Sputum specimen.
- D. Paper mask and gown.
Correct Answer: D
Rationale: Disposable PPE prevents contamination.
A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?
- A. Confirm that bowel sounds are present.
- B. Measure the client's total body weight.
- C. Evaluate the client's ability to swallow.
- D. Observe for signs of fluid volume deficit.
Correct Answer: A
Rationale: Bowel sounds indicate GI function.