A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

Standard

Airborne

Droplet

Contact

Answer and Explanation

The Correct Answer is A

Choice A reason : Standard precautions are the primary strategy for the prevention and control of hepatitis C virus (HCV) transmission. According to the Centers for Disease Control and Prevention (CDC), standard precautions include hand hygiene and the use of personal protective equipment to prevent contact with blood and other potentially infectious materials¹. Since HCV is primarily transmitted through blood-to-blood contact, standard precautions are sufficient for routine care of patients with hepatitis C².

Choice B reason : Airborne precautions are not necessary for hepatitis C as it is not spread through the air. These precautions are used for diseases that are transmitted through airborne droplet nuclei or dust particles containing the infectious agent, such as tuberculosis, measles, or chickenpox¹.

Choice C reason : Droplet precautions are also not required for hepatitis C because it is not spread through droplets in the air. Droplet precautions are used for infections that can be transmitted through large droplets expelled during coughing, sneezing, talking, or during procedures such as suctioning and bronchoscopy¹.

Choice D reason : Contact precautions are not specifically required for hepatitis C unless there is a risk of blood contamination. Contact precautions are typically used for infections that are spread by direct or indirect contact with the patient or the patient's environment, such as gastrointestinal, respiratory, skin, or wound infections¹.

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Correct Answer is D

Explanation

Choice A reason : Abdominal distension is more commonly associated with right-sided heart failure due to fluid accumulation in the abdominal cavity. Left-sided heart failure primarily affects the lungs, leading to respiratory symptoms¹.

Choice B reason : Jugular venous distention is typically a sign of right-sided heart failure, indicating increased pressure in the right atrium and venous system. It is not a primary symptom of left-sided heart failure¹.

Choice C reason : Dependent edema, or swelling in the lower extremities, is also more indicative of right-sided heart failure, where fluid accumulates due to poor venous return. In left-sided heart failure, fluid backs up into the lungs rather than the extremities¹.

Choice D reason : A hacking cough, especially when lying down, is a symptom of left-sided heart failure, as fluid backs up into the lungs causing pulmonary congestion. This can lead to coughing and shortness of breath, particularly during exertion or when lying flat¹.

A. A 40-year-old woman who came into the ER with a swollen, painful calf and now complains of chest pains and having trouble breathing, with tachycardia and tachypnea. B. A 60-year-old man who is tired and has been in the med-surg unit for 3 days with AKI after taking IV antibiotics. C. A 30-year-old man with a history of smoking and a sedentary lifestyle who had an appendectomy 1 day ago and is refusing to ambulate or wear compression stockings. D. A 55-year-old woman who came into the ER with chest pains, shortness of breath, nausea, tachypnea, and radiating jaw pain.

Correct Answer is A

Explanation

Choice A reason : The symptoms described for the 40-year-old woman align closely with the clinical presentation of a pulmonary embolism. Swelling and pain in the calf may indicate deep vein thrombosis (DVT), which can lead to PE. The presence of chest pain, difficulty breathing, rapid heart rate (tachycardia), and rapid breathing (tachypnea) are hallmark signs of PE³⁴.

Choice B reason : While the 60-year-old man is experiencing fatigue, which can be a symptom of many conditions, there is no direct indication of PE. Acute kidney injury (AKI) after IV antibiotics suggests a different pathophysiology unrelated to PE.

Choice C reason : The 30-year-old man's refusal to ambulate or wear compression stockings after surgery increases his risk for DVT and subsequently PE; however, he does not currently exhibit symptoms that are as indicative of PE as the 40-year-old woman.

Choice D reason : The 55-year-old woman's symptoms could suggest a cardiac event, such as a heart attack, especially with the radiating jaw pain. While PE can present with similar symptoms, the radiating pain is more characteristic of cardiac issues³.

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A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

Which patient is most likely experiencing a pulmonary embolism (PE)?

Correct Answer is A

Explanation

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