A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?
Contact
Droplet
Airborne
Standard
The Correct Answer is D
Rationale:
A. Contact: Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment, such as MRSA or C. difficile. Erythema migrans, associated with Lyme disease, is not spread through contact.
B. Droplet: Droplet precautions are for infections transmitted through large respiratory droplets, such as influenza or pertussis. Lyme disease does not spread via respiratory secretions, so droplet precautions are unnecessary.
C. Airborne: Airborne precautions apply to infections transmitted via small particles that remain suspended in the air, such as tuberculosis or measles. Lyme disease is not airborne, so this precaution is not required.
D. Standard: Standard precautions are appropriate for Lyme disease, including erythema migrans. These precautions involve routine hand hygiene, use of gloves when in contact with body fluids, and proper handling of contaminated materials, which are sufficient since the disease is transmitted via tick bites, not person-to-person.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Stair carpeting is attached with carpet tacks: Loose or improperly secured carpeting on stairs creates a significant tripping hazard, especially for clients with mobility limitations such as a hip fracture. Carpet tacks can cause the edges of the carpet to lift, increasing the risk of falls and further injury.
B. Nonessential items are stored in drawers: Storing nonessential items in drawers does not create an immediate fall risk or safety hazard. Keeping items organized in drawers can actually reduce clutter in walking areas, making the environment safer.
C. Magazines are stacked neatly on the stairs: Even neatly stacked magazines on stairs are a potential tripping hazard. However, the option specifies “neatly stacked,” which implies some order, though ideally items should not be on stairs at all. Carpet tacks pose a more immediate and hidden danger than visible items.
D. End tables are secured to the wall: Securing furniture prevents tipping and provides stability, which enhances safety for clients with mobility limitations. This measure decreases the risk of falls and does not pose a hazard.
Correct Answer is C
Explanation
Rationale:
A. Instruct the client to discard the medication in the toilet: Disposing of medication in the toilet is not a recommended first action, as it does not address the client’s question about safely taking a half dose. Safe disposal is only necessary for expired or unwanted medications.
B. Manually break the tablets in half: Manually breaking tablets without knowing if they are designed to be split can lead to inaccurate dosing and affect drug efficacy. Some medications are not safe to split due to extended-release properties or uneven distribution of active ingredients.
C. Determine if the tablets are scored: Scored tablets are specifically designed to be split, ensuring accurate dosing. The nurse should verify whether the medication is scored before advising the client to cut it, ensuring safety and effectiveness of the prescribed dose.
D. Ask the pharmacy to create a liquid version of the medication: While a liquid formulation may be appropriate for accurate dosing if the tablet cannot be safely split, the first step is to confirm whether the current tablet can be divided. The pharmacy can then provide alternatives if splitting is unsafe.
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