Practice Quiz

NCLEX-RN

Category - Care Management

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In the role of team leader, Nina the New Nurse understands that her priority is ensuring that the healthcare team safely meets each client’s need. She does this is by evaluating the care provided by the team members and intervenes when appropriate. Which of the following situations require intervention by Nina the New Nurse?(There may be more than one correct answer.)
  1. A phlebotomist using gloves to draw blood from a post-surgical, infection-free client.
  2. A nursing student using gloves and mask while measuring the blood pressure of a client with acute hepatitis B.
  3. A LPN requesting assistance to logroll a client.
  4. Nursing assistant allowing unmasked visitors into the room of HIV+ client receiving treatment for pneumocystis pneumonia.
Explanation
Answer: B and C -B: Intervention by Nina the New Nurse is necessary to help the nursing student understand that mask and gloves are unnecessary when measuring the blood pressure of a client in contact isolation, and may negatively affect the client’s emotional well-being. Gloves are necessary when contact with blood or body fluids are expected for any client. C: Nina the New Nurse intervenes by first providing assistance to the LPN in safely logrolling the client, and then assesses further intervention by evaluating the delegation of duties. Why wasn’t a nursing assistant available to assist the LPN? Masks are not necessary for visitors of a client being treated for pneumocystis pneumonia.
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