A nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit.
To prevent scabies infection in other clients, the nurse should:
Wash hands, apply a pediculicide to the client's scalp, and remove any observable mites.
Place the client on enteric precautions.
Isolate the client's bed linens until the client is no longer infectious.
Notify the nurse in the day surgery unit of a potential scabies outbreak.
The Correct Answer is C
Choice A rationale
Pediculicides are used to treat lice, not scabies. Proper hand hygiene is important, but applying pediculicide is not necessary for scabies management.
Choice B rationale
Enteric precautions are for infections transmitted via the fecal-oral route, not for scabies, which requires contact precautions.
Choice C rationale
Isolating the client's bed linens and applying contact precautions help prevent the spread of scabies to other clients.
Choice D rationale
Notifying the day surgery unit of a potential scabies outbreak is important, but it does not directly prevent infection in other clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Documenting wound size includes measuring the length, width, and depth of the wound to track the healing process and plan appropriate interventions.
Choice B rationale
The wound bed should be assessed for tissue type (granulation, slough, or eschar), color, and the presence of any exudate or infection.
Choice C rationale
The periwound skin is the area around the wound which should be assessed for color, temperature, swelling, and signs of maceration or excoriation.
Choice D rationale
Pattern of eruption is more relevant to dermatological conditions such as rashes or lesions, and not a primary focus for documenting acute open wounds.
Correct Answer is D
Explanation
Choice A rationale
A 5% deficit in body weight compared to pre-illness weight and increased caloric need may indicate the need for nutritional intervention, but it is not specific to parenteral nutrition. Acute pancreatitis patients often have difficulty maintaining nutritional intake due to pain and digestive issues, but a 5% weight deficit alone isn't a definitive trigger for PN.
Choice B rationale
A significant risk of aspiration and decreased level of consciousness indicates the need for close monitoring and possibly intubation to protect the airway. However, this alone doesn't necessitate parenteral nutrition unless it is combined with the inability to consume adequate nutrition orally or enterally.
Choice C rationale
A calorie deficit, muscle wasting, and low electrolyte levels are serious concerns that warrant nutritional support, but the specific indicator for parenteral nutrition is the inability to meet nutritional needs through oral or enteral routes. PN is a method to provide nutrition when GI tract use is not possible or adequate.
Choice D rationale
Inability to take adequate oral food or fluids within 7 days is a clear indication for parenteral nutrition. For patients with acute pancreatitis who cannot tolerate oral or enteral feeding, PN ensures they receive the necessary nutrients to support recovery and prevent further complications.
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