The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?
Puts on new gloves when entering a client’s room.
Uses sterile gloves when handling body fluids.
Keeps a pair of gloves in uniform pocket.
Dons sterile gloves when caring for clients with HIV.
The Correct Answer is A
Choice A rationale
Puts on new gloves when entering a client’s room. This action demonstrates an understanding of standard precautions, which are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. By putting on new gloves when entering a client’s room, the UAP is ensuring that they are not transferring any pathogens from one environment to another, thereby protecting both themselves and the client.
Choice B rationale
Uses sterile gloves when handling body fluids. While it is important to use gloves when handling body fluids, sterile gloves are not necessary unless performing a sterile procedure. Standard gloves are sufficient for most tasks involving body fluids, and the use of sterile gloves in these situations would be an unnecessary use of resources.
Choice C rationale
Keeps a pair of gloves in uniform pocket. This practice is not recommended as it can lead to contamination of the gloves. Gloves should be stored in a clean, dry place and should be taken from the box immediately before use. Keeping gloves in a pocket can expose them to contaminants, which can then be transferred to the client.
Choice D rationale
Dons sterile gloves when caring for clients with HIV. HIV is not transmitted through casual contact, and standard gloves are sufficient for routine care of clients with HIV. Sterile gloves are only necessary for sterile procedures, regardless of the client’s HIV status.
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Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Monitoring the client’s white blood cell count is essential to assess the presence and severity of infection. An elevated white blood cell count can indicate an ongoing infection, including MRSA.
Choice B rationale
Sending wound drainage for culture and sensitivity is crucial to identify the specific bacteria causing the infection and to determine the most effective antibiotics for treatment.
Choice C rationale
Instituting contact precautions for staff and visitors is necessary to prevent the spread of MRSA. This includes wearing gloves and gowns when entering the client’s room and ensuring proper hand hygiene.
Choice D rationale
Explaining the purpose of a low bacteria diet is not relevant to the management of MRSA infections. MRSA management focuses on infection control measures and appropriate antibiotic therapy.
Choice E rationale
Using standard precautions and wearing a mask is not specific to MRSA management. While standard precautions are always important, contact precautions are more relevant for preventing the spread of MRSA.
Correct Answer is B
Explanation
Choice A rationale
Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response and does not need to be documented in charting by exception. This finding is within normal limits and does not indicate any deviation from the expected outcome.
Choice B rationale
Basilar lung sounds that are diminished in the left lung should be documented because this finding deviates from the normal lung sounds and indicates a potential issue that needs further investigation. Charting by exception focuses on documenting abnormalities or deviations from the norm.
Choice C rationale
Active bowel sounds in the lower right quadrant are a normal finding and do not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.
Choice D rationale
Capillary refill of 2 seconds in the lower right foot is a normal finding and does not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.