A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles.
For which of the following actions by the newly licensed nurse should the charge nurse intervene?
The nurse places the client on airborne precautions.
The nurse has the client wear a mask for transport to radiology.
The nurse wears an N95 respirator when performing client care.
The nurse ensures the client's room maintains a positive airflow.
The Correct Answer is D
Choice A rationale:
Placing the client on airborne precautions for measles is the appropriate action. Measles is highly contagious and spreads through respiratory droplets. Airborne precautions, including wearing a mask, are essential to prevent the transmission of the virus to others. This action is in line with infection control protocols and ensures the safety of both healthcare providers and other patients.
Choice B rationale:
Having the client wear a mask for transport to radiology is a necessary precaution to prevent the spread of measles to others in the healthcare facility. It helps contain respiratory droplets and reduces the risk of transmission. This action aligns with infection control guidelines and is appropriate in this context.
Choice C rationale:
Wearing an N95 respirator when caring for a client with measles is necessary to protect healthcare providers from inhaling infectious particles. Measles is highly contagious, and airborne precautions, including the use of appropriate respiratory protection, are crucial. This action demonstrates the nurse's understanding of infection control measures.
Choice D rationale:
Ensuring the client's room maintains a positive airflow is wrong in an airborne infection isolation room. Negative airflow helps prevent the contaminated air from flowing out of the room and spreading the infection to other areas of the healthcare facility. This action is consistent with the recommended infection control practices for airborne diseases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Have the client wear a surgical mask while being transported outside the room.
- A. Initiate contact precautions for the client upon admission. This is incorrect because contact precautions are not sufficient to prevent the spread of TB, which is an airborne disease that can travel through small droplets in the air.
- B. Restrict visitors from entering the client's room during hospitalization. This is incorrect because visitors can enter the client's room as long as they wear appropriate personal protective equipment (PPE) such as an N95 respirator, gown, gloves, and eye protection.
- C. Wear a surgical mask while providing care for the client. This is incorrect because a surgical mask does not filter out small airborne particles that carry TB bacteria. The nurse should wear an N95 respirator or higher level of respiratory protection when caring for a client who has active TB.
- D. Have the client wear a surgical mask while being transported outside the room. This is correct because a surgical mask can reduce the amount of droplets that are expelled by the client when coughing or sneezing, thus minimizing the risk of infecting others in common areas or hallways.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should include the statement, "Use a product with DEET on your skin and clothes when you are walking in a wooded area," in the educational program on Lyme disease. DEET is a widely used insect repellent effective against ticks. It is recommended to prevent tick bites in wooded and grassy areas. The rationale behind this choice is to educate the public about practical measures to reduce the risk of Lyme disease. DEET repels ticks, reducing the chances of tick attachment and, consequently, the transmission of Lyme disease.
Choice B rationale:
The statement, "Symptoms of Lyme disease appear 2 days after being bitten by an infected tick," is incorrect. The incubation period for Lyme disease can vary from 3 to 30 days after the tick bite. Symptoms usually appear within 3 to 14 days but can take longer to manifest. Providing inaccurate information can lead to misunderstanding and inadequate preventive measures.
Choice C rationale:
The statement, "Remove embedded ticks by squeezing the body with tweezers," is incorrect. Improper removal of ticks, such as squeezing the body, can lead to the injection of tick fluids into the host, increasing the risk of disease transmission. The correct method for tick removal is to use fine-tipped tweezers to grasp the tick as close to the skin's surface as possible and pull upward with steady, even pressure. This helps ensure the tick is removed entirely and reduces the risk of infection.
Choice D rationale:
The statement, "If bitten by a tick, testing for Lyme disease should occur within 2 weeks," is incorrect. Testing for Lyme disease immediately after a tick bite is not recommended because it takes time for the body to produce antibodies detectable by the tests. Testing too early can yield false-negative results. Healthcare providers may recommend testing if symptoms develop, but waiting for a few weeks after the bite increases the accuracy of the test results.
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