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 C
Explanation
Rationale
A. Educate the client about potential adverse effects: Education is important but is not the immediate priority. Ensuring the client’s physiological stability takes precedence over providing information after an overdose. Education can follow once the client’s condition is assessed.
B. Complete an incident report: Completing an incident report is necessary for documentation and quality improvement, but it does not address the client’s immediate safety. Reporting comes after assessing and stabilizing the client.
C. Obtain the client's vital signs: Assessing vital signs is the first action because it provides critical information about the client’s current physiological status. Monitoring for changes in blood pressure, heart rate, respiratory rate, and oxygen saturation helps identify early signs of adverse reactions and guides urgent interventions.
D. Notify the primary care provider: Notifying the provider is important to determine further medical management, but it should occur after assessing the client’s vital signs to provide accurate and current information about their condition. Immediate assessment ensures timely and appropriate provider guidance.
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.
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