a female uap is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented the uap requests a chan
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Nursing Elites

HESI RN

HESI Fundamentals Quizlet

1. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct answer: C

Rationale: The correct answer is C. For droplet precautions, such as in the case of pertussis, a standard face mask is sufficient for protection. Particulate filter masks are required for airborne precautions, not for droplet precautions. Therefore, the UAP can proceed with taking the vital signs using a standard mask without the need for a particulate filter mask. Choice A is incorrect because the UAP does not need to get fitted for a particulate filter mask before providing care in this situation. Choice B is incorrect as fitting for a particulate filter mask is not necessary for droplet precautions. Choice D is also incorrect because determining which staff members have fitted particulate filter masks is not relevant to the UAP's situation with the client on droplet precautions. It is important for healthcare workers to understand the appropriate use of personal protective equipment based on the type of precautions in place to provide safe and effective care to clients.

2. The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

Correct answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

3. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?

Correct answer: D

Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.

4. During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?

Correct answer: D

Rationale: The ability to read a Snellen chart from 20 feet away indicates intact cranial nerve II (optic nerve), responsible for vision. Hearing a whisper (A) is associated with cranial nerve VIII (vestibulocochlear nerve), identifying an object by touch (B) is related to cranial nerves V (trigeminal nerve) and VII (facial nerve), and shoulder shrugging against resistance (C) is a test for cranial nerve XI (accessory nerve). Thus, the correct answer is D as it specifically tests the function of cranial nerve II.

5. The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

Correct answer: D

Rationale: When encountering a client in distress, the nurse's initial response should be to communicate with the client to assess the situation and provide support. By talking to the client and attempting to find out the reason for their distress, the nurse can offer appropriate assistance and ensure the client's well-being. This action prioritizes the client's emotional needs and helps establish a therapeutic relationship, which is essential in nursing care.

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