A nurse in the Medical-Surgical unit is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?
Airborne.
Contact.
Droplet.
Protective.
The Correct Answer is B
The correct answer is: d. Protective. Protective precautions are crucial for clients who have had an allogeneic hematopoietic stem-cell transplant due to their severely weakened immune systems.
Choice A reason:
Airborne precautions are used for infections that spread through the air, such as tuberculosis and measles. These infections require special ventilation and respiratory protection, which is not the primary concern for stem-cell transplant patients.
Choice B reason:
Contact precautions are used for infections spread by direct contact, like MRSA or C. difficile. These precautions involve wearing gloves and gowns but do not address the airborne or droplet risks that immunocompromised patients face.
Choice C reason:
Droplet precautions are for infections spread by large respiratory droplets, such as influenza or pertussis. While important, they do not provide the comprehensive protection needed for stem-cell transplant recipients.
Choice D reason:
Protective precautions involve placing the patient in a room with HEPA filtration and limiting visitors to minimize infection risk. This is essential for patients with compromised immune systems, such as those who have undergone allogeneic hematopoietic stem-cell transplants.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Hypotension is not an expected manifestation of hypoxemia during an asthma attack. Hypotension refers to abnormally low blood pressure. During an asthma attack, the body's response to hypoxemia is more likely to involve increased heart rate (tachycardia) as the heart attempts to compensate for decreased oxygen levels.
Choice B rationale:
Dysphagia is not directly related to hypoxemia during an asthma attack. Dysphagia refers to difficulty swallowing, which is not a typical respiratory manifestation. Hypoxemia in asthma is more likely to lead to symptoms such as shortness of breath, wheezing, and increased work of breathing.
Choice C rationale:
Peripheral edema is not a typical manifestation of hypoxemia during an asthma attack. Peripheral edema, or swelling in the extremities, can occur in conditions like heart failure but is not directly related to the airway constriction and reduced oxygen exchange seen in asthma attacks.
Choice D rationale:
Agitation is the correct choice. Hypoxemia, which occurs when there is a decrease in the oxygen levels in the blood, can lead to inadequate oxygen supply to the brain. This can result in neurological symptoms such as agitation, restlessness, confusion, and even loss of consciousness. Agitation is a manifestation of the body's attempt to cope with the lack of oxygen.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
This choice is not correct because verifying the oxygen flow rate every other day is not part of the discharge teaching for a client on home oxygen therapy. The flow rate should be checked regularly, not just every other day, to ensure the client's safety and well-being.
Choice B rationale:
This choice is correct. Checking the tops of the ears for skin breakdown is important in a client using a nasal cannula for oxygen therapy. Prolonged use of the cannula can lead to irritation and pressure-related skin breakdown behind the ears.
Choice C rationale:
This choice is correct. Posting "no smoking signs in a prominent location in the home" is an important safety measure for a client on oxygen therapy. Oxygen supports combustion, and smoking in the presence of oxygen can lead to fire hazards.
Choice D rationale:
This choice is correct. Checking the cannula position on a regular basis is essential to ensure that the oxygen is being delivered effectively and that the client is not experiencing discomfort or skin breakdown due to improper positioning.
Choice E rationale:
This choice is correct. Applying petroleum ointment to the nares if they become dry and irritated is a suitable intervention to maintain the client's comfort and prevent skin irritation from the cannula.
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