A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

Droplet

Airborne

Contact

Protective environment

Answer and Explanation

The Correct Answer is A

A. Droplet: Correct. Pneumonia is transmitted by respiratory droplets that are generated by coughing, sneezing, or talking. The nurse should wear a surgical mask and eye protection when caring for the client and maintain a distance of at least 3 feet from the client.

B. Airborne: Incorrect. Airborne precautions are used for diseases that are transmitted by small particles that remain suspended in the air for long periods of time, such as tuberculosis, measles, or chickenpox. The nurse should wear a respirator and place the client in a negative-pressure room.

C. Contact: Incorrect. Contact precautions are used for diseases that are transmitted by direct or indirect contact with the client or the client's environment, such as Clostridium difficile, scabies, or MRSA. The nurse should wear gloves and a gown and use dedicated equipment for the client.

D. Protective environment: Incorrect. Protective environment precautions are used for clients who are immunocompromised and at risk of infection from others, such as clients who have had a stem cell transplant or are receiving chemotherapy. The nurse should wear a mask, gloves, and a gown and place the client in a positive-pressure room with HEPA filtration.

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Correct Answer is A

Explanation

A.This action is the best first step as it engages staff members directly in identifying the underlying causes of staffing difficulties. Involving staff in the problem-solving process can lead to more effective solutions and promote buy-in for any changes.

B.While supporting staff is important, this step should come after understanding the issues and gathering input. Addressing resistance without first identifying the root causes may not be effective.

C.While communication is important, presenting options without first gathering input and understanding the current issues may not address the root problems. A meeting should follow the investigation and data collection.

D.Notifying staff of changes is important, but it should come after the issues are investigated and a plan is formed. Implementing changes without understanding staff concerns may lead to further dissatisfaction.

A. Assess peripheral circulation hourly. B. Assess the client's mouth every 8 hr. C. Use humidification with oxygen therapy. Administer IV fluids. D. Raise the knee position on the client's bed. E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion.

Correct Answer is ["A","B","C"]

Explanation

A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.

B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.

C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.

D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.

E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vaso-occlusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.

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A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

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Explanation

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Explanation

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