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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Rationale:

A. WBC count 10,000/mm³ (5,000 to 10,000/mm³): This value is at the upper limit of normal. Mild elevations can occur during early pregnancy due to physiological changes and do not typically require immediate reporting unless accompanied by signs of infection.

B. Fasting blood glucose 80 mg/dL (74 to 106 mg/dL): This value falls within the normal fasting glucose range for adults and is not concerning during early pregnancy. No intervention or reporting is necessary for this result.

C. Hematocrit 30% (37% to 47%): This value is below the normal range, indicating anemia. Early pregnancy anemia can increase the risk of maternal fatigue, preterm birth, and low birth weight. The nurse should report this finding to the provider for further evaluation and possible iron supplementation.

D. RBC count 6 million/mm³ (4.2 to 6.1 million/mm³): This value is within the normal range for red blood cells. It does not indicate any immediate concern and does not require reporting to the provider.

A. The client's frequency of incontinence has decreased. B. The client's iron level has increased. C. The client's high-density lipoprotein level has increased. D. The client's HbA1c has decreased.

Correct Answer is D

Explanation

Rationale:

A. The client's frequency of incontinence has decreased: Incontinence is not a direct measure of blood glucose control or the effectiveness of metformin. Changes in urinary frequency may be influenced by other conditions, such as urinary tract infections or prostate issues, and do not indicate the medication’s success.

B. The client's iron level has increased: Metformin does not affect iron metabolism. An increase in iron levels would be unrelated to metformin therapy and could reflect dietary changes, supplementation, or other underlying conditions.

C. The client's high-density lipoprotein level has increased: While metformin may have mild beneficial effects on lipid profiles, its primary purpose is to improve glycemic control. Changes in HDL are not the main indicator of therapeutic success for this medication.

D. The client's HbA1c has decreased: HbA1c reflects average blood glucose levels over the past 2–3 months. A decrease indicates improved glycemic control, which is the primary goal of metformin therapy. Monitoring HbA1c is the most reliable measure to evaluate the effectiveness of the medication.

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A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

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Naxlex Comprehensive Predictor Exams

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