A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?
Airborne
Contact
Droplet
Protective
The Correct Answer is C
A. Airborne:
Airborne precautions are used for infections transmitted via small droplet nuclei that remain suspended in the air for long periods and can be inhaled by others. Examples of diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. Pertussis is not transmitted via the airborne route.
B. Contact:
Contact precautions are used for infections spread by direct or indirect contact with the client or their environment. Examples include Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Pertussis is primarily spread through respiratory droplets rather than contact with contaminated surfaces.
C. Droplet:
Pertussis is primarily spread through respiratory droplets when an infected person coughs or sneezes. The nurse should initiate droplet precautions to prevent the transmission of the bacteria to others. These include wearing a surgical mask when within 3 feet of the client, placing the client in a private room or cohorting with another client who has the same infection, and ensuring that visitors wear masks and practice hand hygiene.
D. Protective:
Protective precautions, also known as reverse isolation, are used to protect clients who have compromised immune systems from exposure to pathogens. This precaution is not relevant for a client with pertussis; instead, the focus is on preventing transmission to others through droplet precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. "I should expect the hospice team to help me manage my dyes."
A. "I will have to be admitted to a long-term care facility in order to receive hospice care."
This statement reflects a misunderstanding of hospice care. Hospice services can be provided in various settings, including the client’s home, hospice centers, or even long-term care facilities, but clients are not required to be admitted to a long-term care facility specifically to receive hospice care.
B. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."
Hospice care focuses on comfort and quality of life for clients with terminal illnesses, rather than curative treatment. Clients receiving hospice care have typically decided to forego curative treatment to prioritize symptom management and palliative care.
C. "I should expect the hospice team to help me manage my dyes."
This statement indicates an understanding of hospice care. The hospice team provides comprehensive support to manage symptoms, such as pain and discomfort, as well as addressing emotional, spiritual, and psychosocial needs. The goal is to ensure the client’s comfort during the end of life.
D. "Hospice care services are available to patients who are terminally ill regardless of their life expectancy."
This is not entirely accurate. Hospice care is typically available to individuals who have a life expectancy of six months or less, as determined by their healthcare provider. Therefore, life expectancy is an important criterion for hospice eligibility.
Correct Answer is D
Explanation
A. Collect a urine sample from the client: While collecting a urine sample may be necessary for further assessment, it is not the priority in this situation. The client's symptoms of lower back pain, feeling chilled, and itching suggest a potential transfusion reaction, which requires immediate attention to ensure the client's safety. Therefore, collecting a urine sample is not the most appropriate initial action.
B. Return the platelet bag and tubing to the blood bank: Returning the platelet bag and tubing to the blood bank may be necessary after stopping the infusion, but it is not the first action the nurse should take. Stopping the infusion and assessing the client's condition are the immediate priorities to address the potential transfusion reaction.
C. Notify the provider: While it is important to notify the provider about the client's symptoms and the suspected transfusion reaction, this action should follow after stopping the infusion and assessing the client's condition. Immediate intervention to ensure the client's safety takes precedence over contacting the provider.
D. Stop the infusion: This is the correct action. The client's symptoms of lower back pain, feeling chilled, and itching are indicative of a potential transfusion reaction, such as febrile non-hemolytic transfusion reaction or allergic reaction. The immediate priority is to stop the infusion to prevent further administration of platelets and assess the client's condition. This action takes precedence over other interventions as addressing the client's safety and well-being is paramount in the event of a transfusion reaction.
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