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An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Send the UAP to be fitted for a particulate filter mask immediately.
- B. Instruct the UAP that a standard face mask is sufficient.
- C. Before changing assignments, determine which staff members have fitted particulate filter masks.
- D. Advise the UAP to wear a standard face mask to obtain vital signs.
Correct Answer: B
Rationale: Standard mask suffices for droplet precautions.
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The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?
- A. Offering therapeutic support to a grieving family.
- B. Obtaining clarification from a client’s healthcare power-of-attorney.
- C. Reporting a change in a client’s condition to the healthcare provider.
- D. Completing discharge teaching to a client and family members.
Correct Answer: C
Rationale: SBAR is for clinical communication.
The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?
- A. Advise the UAP to hold the thermometer securely in place for a full three minutes.
- B. Use positive reinforcement to affirm that the procedure is being performed correctly.
- C. Demonstrate the correct technique for pulling the client’s auricle down and back.
- D. Remind the UAP to lubricate the thermometer before gently inserting it in the ear.
Correct Answer: B
Rationale: Up-and-back is correct for adults.
What times should the nurse measure vital signs? Select all that apply.
- A. 1500
- B. 1600
- C. 1800
- D. 1000
- E. 1200
Correct Answer: A,B,C,G,H
Rationale: Times align with fever monitoring.
The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?
- A. Ensure bevel of the needle is pointing up.
- B. Massage the site gently after injection.
- C. Hold the syringe perpendicular to the skin.
- D. Select upper arm as the injection site.
Correct Answer: A
Rationale: Bevel up ensures proper delivery.
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?
- A. Self-care deficit.
- B. Impaired physical mobility.
- C. Risk for infection.
- D. Risk for impaired skin integrity.
Correct Answer: D
Rationale: Neuropathy increases skin breakdown risk.