A nurse in an emergency department is planning care for a group of clients. Which of the following clients should the nurse plan to place in an airborne isolation room?
A client who has respiratory syncytial virus
A client who has varicella
A client who is undergoing a bone marrow transplant
A client who has Clostridioides difficile
The Correct Answer is B
Rationale
A. A client who has respiratory syncytial virus: RSV is spread through droplet and direct contact, not airborne transmission. Standard precautions with droplet precautions are sufficient, so an airborne isolation room is not required.
B. A client who has varicella: Varicella (chickenpox) is transmitted via airborne particles. Placing the client in an airborne isolation room with negative pressure prevents the spread of infectious aerosols to other clients and staff, making this the appropriate intervention.
C. A client who is undergoing a bone marrow transplant: While these clients are immunocompromised and may require protective isolation, the need is for neutropenic precautions, not airborne isolation, unless they are exposed to a specific airborne infection.
D. A client who has Clostridioides difficile: C. difficile is transmitted via contact with spores, not airborne routes. Contact precautions and proper hand hygiene with soap and water are required, but an airborne isolation room is unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Circular Red Area: This is a Stage 1 Pressure Injury (non-blanchable erythema or shallow ulcer).
B. Bruise on Leg: This shows contusion/bruising (ecchymosis) and possible swelling, which is a closed injury, not an open wound that requires healing by intention.
C. Sutured Incision (Primary intention): The wound edges are cleanly approximated (brought together) with sutures, staples, or adhesive. Minimal tissue loss occurred. Healing occurs rapidly, with minimal granulation tissue and minimal scarring. The image showing the clean, surgical incision closed with staples or sutures.
D. Open Ulcer/Pressure Injury (Secondary Intention): The wound has significant tissue loss, irregular borders, and the edges cannot be approximated (closed). The wound is left open to heal by granulation (formation of new connective tissue) from the bottom up. This process is slower and results in a larger, more noticeable scar.
Correct Answer is A
Explanation
Rationale
A. Keep the head of the client's bed at 30° or less: Elevating the head of the bed to 30° or less reduces pressure on the sacrum and heels, which are common sites for pressure injury in immobile clients. Maintaining this position helps prevent shear and friction forces that contribute to skin breakdown.
B. Bathe the client with soap and hot water: Using soap and hot water can strip natural oils from the skin, increasing dryness and the risk of breakdown. Gentle cleansing with lukewarm water and mild, pH-balanced soap is recommended to preserve skin integrity.
C. Slide the client up in bed every 2 hr: Sliding the client up in bed creates shear and friction forces on the skin, which can exacerbate pressure injuries. Repositioning should involve lifting or using a draw sheet to move the client safely without dragging the skin.
D. Massage bony prominences four times daily: Massaging bony prominences can damage underlying tissue and worsen skin breakdown. Pressure should be relieved through repositioning and support surfaces rather than direct massage of high-risk areas.
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