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The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature 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. Remind the UAP to locate the thermometer before gently inserting the ear.
- B. Demonstrate the correct technique for pulling the client's auricle up and back.
- C. Advise the UAP to hold the thermometer securely in place to obtain the measurement.
- D. Use positive reinforcement to affirm that the procedure being performed correctly.
Correct Answer: D
Rationale: The UAP is correctly pulling the client's auricle up and back and preparing to insert the thermometer.
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A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections.Which intervention is most appropriate to prevent the spread of MRSA to others?
- A. Change coccyx dressing after performing routine care.
- B. Change coccyx dressing before performing routine care.
- C. Restate the vital importance of performing hand hygiene.
- D. Perform coccyx dressing change in the nursing station.
Correct Answer: C
Rationale: Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing.
An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments.What action should the nurse take first?
- A. Send the UAP to be educated on how to care for a foot ulcer.
- B. Advise the UAP to wear gloves when caring for the FP.
- C. Instruct the UAP to start with basic wound care precautions.
- D. Ask the UAP which action they would take first and state why.
Correct Answer: A
Rationale: It is important for the UAP to receive proper education and training on how to care for a foot ulcer before being assigned to care for a client with this condition.
The nurse is preparing to give an emergency sedative injection to an agitated client.Which action by the nurse is inappropriate?
- A. Placing a client in restraints without having a healthcare provider's order.
- B. Administering the medication to a client behind a closed curtain.
- C. Enlisting security personnel to assist with restraining the client.
- D. Informing a client that the medication being administered is a sedative.
Correct Answer: A
Rationale: Placing a client in restraints without having a healthcare provider's order is inappropriate for a nurse to do.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
What's the priority intervention for a patient with persistent STIs and risky behaviors?
- A. Recommend consistent use of latex condoms.
- B. Discuss the purpose of annual infection screening.
- C. Some infections may have no initial symptoms.
- D. Advise that alcohol intake may lead to risky behaviors.
Correct Answer: A
Rationale: The priority intervention for a patient with persistent STIs and risky behaviors is to recommend consistent use of latex condoms. According to the USPSTF, behavioral counseling is recommended for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).