A client has been placed on Contact Precautions. The client’s family is very afraid to visit. What is the best action for the nurse to take?

Demonstrate to the family how to avoid spreading the disease.

Reassure the family that they will not get the infection.

Encourage the family that it is important that they visit the client.

Inform them that these precautions are mandated by law.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Addresses the family's fear directly: By demonstrating how to avoid spreading the disease, the nurse directly addresses the family's primary concern, which is the fear of contracting the infection. This proactive approach provides education and reassurance, empowering the family to make informed decisions about visitation.
Promotes understanding and adherence to precautions: Clear instruction on how to don and doff personal protective equipment, hand hygiene techniques, and other infection control measures increases the likelihood that the family will follow the precautions correctly, reducing the risk of transmission.
Empowers the family to make informed choices: By providing knowledge and skills, the nurse enables the family to feel more confident in their ability to visit safely. This sense of control can help to alleviate anxiety and promote positive coping mechanisms.
Facilitates open communication and trust: The demonstration creates an opportunity for the nurse to answer questions, address concerns, and build rapport with the family. This open dialogue can foster trust and collaboration, which are essential for effective care.
Choice B rationale:
May provide false reassurance: While it's important to offer support and hope, it's not always possible to guarantee that family members will not contract the infection. Absolute reassurances could potentially lead to complacency or disregard for precautions, increasing the risk of transmission.
Fails to address the need for education: Simply stating that the family won't get sick doesn't provide them with the knowledge and skills needed to protect themselves and the client. This lack of understanding could result in accidental transmission.
Choice C rationale:
May pressure the family: Encouraging visitation without addressing underlying fears and concerns could be perceived as pressure, leading to resentment, anxiety, or even avoidance. It's important to respect the family's decision-making process and provide support regardless of their choice.
Doesn't prioritize safety: While emotional support is important, the primary focus should be on ensuring the safety of both the client and the family. Encouraging visitation without proper education and precautions could compromise safety.
Choice D rationale:
Focuses on compliance rather than understanding: Informing the family about legal mandates may come across as authoritarian and could potentially increase anxiety or resistance. It's more effective to focus on the rationale behind the precautions and emphasize their role in protecting both the client and the family.

Misses an opportunity to build trust: Simply stating the rules without engaging in dialogue may hinder open communication and trust-building. Taking a collaborative approach and addressing concerns can lead to better understanding and adherence to precautions.

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Correct Answer is ["A","B","F","G"]

Explanation

Rationale for A: Hemoglobin and Hematocrit
Hemoglobin (Hgb) of 6.8 g/dL is significantly below the normal range of 12-16 g/dL for women and 14-18 g/dL for men. This indicates severe anemia, which can cause several of the patient's reported symptoms, including shortness of breath, fatigue, dizziness, and intolerance to cold. It's crucial to address this promptly as severe anemia can lead to tissue hypoxia and organ damage.
Hematocrit (Hct) of 21.2% is also below the normal range of 36-46% for women and 41-50% for men. Hct measures the percentage of red blood cells in the blood, and its low value further confirms the presence of anemia.

Rationale for B: Blood Pressure 100/68, Respirations 24
Blood pressure of 100/68 mmHg is considered low, especially in a patient with a history of hypertension. This could be due to the anemia, as low red blood cell count can decrease blood volume and subsequently lower blood pressure. It's essential to monitor the patient's blood pressure closely, as hypotension can lead to dizziness, fainting, and even shock.
Respirations of 24 breaths per minute are slightly elevated above the normal adult range of 12-20 breaths per minute. This could be a compensatory mechanism for the anemia, as the body tries to increase oxygen intake. However, it could also indicate other underlying respiratory issues that need to be investigated.

Rationale for F: Shortness of breath with exertion
Shortness of breath (dyspnea) is a common symptom of anemia, as the body struggles to deliver enough oxygen to tissues during physical activity. This symptom warrants immediate attention, as it can significantly impact the patient's quality of life and could potentially signal worsening anemia or other cardiopulmonary problems.

Rationale for G: Dizziness when standing
Dizziness upon standing (orthostatic hypotension) is a sign of low blood pressure, which can be exacerbated by anemia. This can increase the risk of falls and injuries, especially in a patient with other health conditions. It's crucial to address this symptom to prevent potential complications.

A. Implement a policy to remove urinary catheters promptly. B. Educate staff members about infection control methods. C. Ensure patients are placed in appropriate isolation. D. Monitor staff members’ hand hygiene practices.

Correct Answer is B

Explanation

Choice A rationale:

While promptly removing urinary catheters can reduce the risk of catheter-associated urinary tract infections (CAUTIs), it addresses only one specific type of infection. It doesn't comprehensively address other common healthcare-associated infections (HAIs) like central line-associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections (CDI).

Education about infection control methods, however, encompasses a broader range of preventive measures that can be applied to various HAIs, making it a more effective strategy for overall infection prevention.

Choice C rationale:

Placing patients in appropriate isolation can prevent the spread of infections, but it's a reactive measure that's implemented after an infection has already occurred. It doesn't address the root causes of infections or prevent their occurrence in the first place.

Education about infection control methods, on the other hand, is a proactive approach that aims to prevent infections from happening in the first place by teaching staff about proper hygiene practices, aseptic techniques, and other infection prevention strategies.

Choice D rationale:

Monitoring hand hygiene practices is crucial for infection prevention, but it's only one aspect of a comprehensive infection control program. Education about infection control methods goes beyond hand hygiene and covers various other preventive measures, such as:

Proper use of personal protective equipment (PPE) Aseptic technique during invasive procedures

Proper cleaning and disinfection of equipment and surfaces Proper handling of patient waste

Recognition of signs and symptoms of infection Prompt reporting of potential outbreaks

Therefore, educating staff members about infection control methods is the most effective action the nursing manager can take to prevent infections in the hospital unit because it provides a comprehensive approach to infection prevention, addressing various aspects of HAI prevention and promoting a culture of safety among healthcare staff.

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A client has been placed on Contact Precautions. The client’s family is very afraid to visit. What is the best action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","F","G"]

Explanation

A nursing manager is worried about the number of infections in the hospital unit. What action by the manager would be most effective in preventing these infections?

Correct Answer is B

Explanation

Choice A rationale:

Choice C rationale:

Choice D rationale:

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