The correct answer is b. Remind the UAP to apply a fitted respirator mask before entering the client’s room.

Influenza is a contagious respiratory illness that can spread through droplets from coughing, sneezing, or talking. To prevent the transmission of influenza, healthcare personnel (HCP) should wear appropriate personal protective equipment (PPE) when caring for clients with suspected or confirmed influenza. According to the CDC, the PPE for influenza includes a gown, gloves, eye protection, and a fitted respirator mask (such as N95) that covers the nose and mouth3. A face mask is not sufficient to protect against influenza, as it does not filter out small particles that may contain the virus.

Therefore, the nurse should remind the UAP to apply a fitted respirator mask before entering the client’s room, as this is the most effective way to prevent the exposure and transmission of influenza. The other options are not correct because:

a. Reviewing the need for the UAP to wear a face mask is not enough, as a face mask does not provide adequate protection against influenza.
c. Assigning the UAP to provide care for another client and assuming full care of the client is not necessary, as the UAP can safely care for the client with influenza if they wear the proper PPE.
d. Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is important, but it does not address the immediate risk of influenza transmission.

The correct answer is Choice C, the system is working properly.

Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained

Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops

Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped

Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed

Choice A rationale:

While it is essential to avoid multitasking and focus on one client at a time, this statement does not specifically pertain to medication administration. It is a general nursing principle for providing safe and effective care.

Choice B rationale:

While informing clients about the action of each medication is crucial for their understanding, the charge nurse should emphasize the importance of reading medication labels thoroughly before administration, which is more directly related to medication safety.

Choice C rationale:

This is the correct answer. Reading medication labels at least two times before administration is essential to ensure the right medication, dosage, route, and time. It is a crucial step in medication safety protocols and helps prevent medication errors.

Choice D rationale:

Completing an incident report after a client vomits after taking a medication is a necessary documentation step but does not directly address the prevention of medication errors, which is the focus of the question.

Choice A rationale:

Evaluating the client for further suicidal behavior is important, but the immediate concern in this situation is the client's safety and managing the effects of the ingested diazepam. Initiating seizure precautions is a more urgent action.

Choice B rationale:

Administering flumazenil to the client is not the first-line treatment for benzodiazepine overdose. Flumazenil may precipitate seizures in patients who are physically dependent on benzodiazepines. The priority is to maintain airway, breathing, and circulation, and manage the symptoms, such as providing respiratory support.

Choice C rationale:

Monitoring the client's IV site for thrombophlebitis is essential but not the immediate priority. The client's respiratory depression and lethargy require urgent intervention to prevent further deterioration.

Choice D rationale:

This is the correct answer. Initiating seizure precautions is crucial in this situation because benzodiazepine overdose can lead to seizures, especially during the recovery phase as the drug's effects wear off. Implementing seizure precautions, such as padding the siderails and ensuring a safe environment, helps prevent injury during a seizure episode.

Choice A rationale:

Weight gain is a common side effect of many antipsychotic medications, including haloperidol. While it is important to monitor for this adverse effect, it is not specifically related to the extrapyramidal symptoms associated with haloperidol use.

Choice B rationale:

Dry mouth is a common anticholinergic side effect of antipsychotic medications like haloperidol. Although it is important to monitor for this adverse effect, it is not specifically related to the extrapyramidal symptoms, such as parkinsonism, associated with haloperidol use.

Choice C rationale:

This is the correct answer. Shuffling gait, or parkinsonism, is an extrapyramidal symptom associated with the use of antipsychotic medications like haloperidol. It is a movement disorder characterized by a shuffling walk, rigidity, and tremors. Recognizing and reporting this symptom promptly is crucial, as it may indicate the development of a serious neurological condition called tardive dyskinesia.

Choice D rationale:

Sedation is a common side effect of haloperidol and other antipsychotic medications. While it is important to monitor for sedation, it is not specifically related to the extrapyramidal symptoms associated with haloperidol use, as described in choice C.

The correct answer is Choice C.

Choice A rationale: Eating a meal prior to postural drainage is not recommended.Postural drainage uses gravity to help clear mucus from the lungs, and having a full stomach can cause discomfort and potentially lead to vomiting1.

Choice B rationale: Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas.Most people with cystic fibrosis benefit from taking pancrelipase to aid their digestion2. However, it is not specifically required prior to postural drainage.

Choice C rationale: Using an albuterol inhaler prior to postural drainage is beneficial.Albuterol is a bronchodilator that helps open the airways, making it easier to clear mucus from the lungs34. This is why it’s recommended to use prior to postural drainage.

Choice D rationale: While maintaining good oral hygiene is important for overall health, it is not specifically required prior to postural drainage

The correct answer is Choice B.

Choice A rationale: Maintaining bed elevation at 20 degrees is not recommended. The recommended bed elevation for patients receiving enteral tube feedings is at least 30 to 45 degrees.This is to prevent aspiration of the feeding solution into the lungs1.

Choice B rationale: Flushing the tubing with 30 mL of water every 4 hours is a recommended practice.This helps to maintain the patency of the feeding tube and prevent clogging1.

Choice C rationale: Checking for gastric residual every 12 hours is not sufficient.For patients receiving continuous tube feedings, gastric residual volume (GRV) should be monitored every 4 hours1.This helps to assess tolerance to the feeding and prevent complications such as aspiration1.

Choice D rationale: Placing enough formula in the container to last 18 hours is not recommended.For an open system, the formula should be replaced every 4 hours to prevent bacterial growth1.