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 B
Explanation
Aspirate contents from the tube and verify the pH level.
- A. This is an incorrect action. Inserting air in the tube and listening for gurgling sounds in the epigastric area is not a reliable method to confirm NG tube placement, as it can produce falsepositive results due to air entering the stomach or intestines.
- B. This is a correct action. Aspirating contents from the tube and verifying the pH level is a valid method to confirm NG tube placement, as gastric contents typically have a pH of less than 5.5, while intestinal or respiratory contents have a higher pH.
- C. This is an incorrect action. Reviewing the medical record for previous x-ray verification of placement is not sufficient to confirm NG tube placement, as the tube can migrate or become dislodged after insertion. X-ray verification should be done initially and whenever there is doubt about the tube's position.
- D. This is an incorrect action. Auscultating the lungs for adventitious breath sounds is not a specific method to confirm NG tube placement, as it can indicate other conditions such as pneumonia or pulmonary edema. It can also miss signs of respiratory complications due to NG tube misplacement, such as pneumothorax or bronchial obstruction.
Correct Answer is D
Explanation
Take the medication 15 min before playing sports.
- A. Clean the mouthpiece with warm water every 2 weeks. This is incorrect because the mouthpiece should be cleaned with warm water at least once a week, or more often if used frequently, to prevent bacterial growth and contamination.
- B. Wait 10 seconds between inhalations. This is incorrect because the recommended time interval between inhalations is 1 minute, not 10 seconds, to allow adequate absorption of the medication and prevent overdose or side effects.
- C. Take a quick inhalation when pressing the dispenser. This is incorrect because a quick inhalation can cause poor coordination of hand-mouth movement and result in less medication reaching the lungs. The nurse should instruct the child to take a slow, deep inhalation when pressing the dispenser, hold their breath for 10 seconds, and exhale slowly.
- D. Take the medication 15 min before playing sports. This is correct because albuterol is a short-acting bronchodilator that can prevent exercise-induced bronchospasm. The nurse should teach the child to take the medication before engaging in physical activity that can trigger asthma symptoms, such as sports, cold weather, or allergens.
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