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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?

Droplet

Airborne

Contact

Protective environment

Answer and Explanation

The Correct Answer is A

Droplet.

The rationale for each choice is as follows:

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. The nurse should discourage raw fruits due to risk of infection.

- B. There is no standard recommendation against exposure to young children.

- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.

- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.

A. Decreased blood pressure B. Decreased hallucinations C. Decreased cholesterol D. Decreased esophageal reflux

Correct Answer is B

Explanation

- A: Incorrect. Decreased blood pressure is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be monitored and reported.

- B: Correct. Decreased hallucinations are an indication of chlorpromazine effectiveness, as this medication is an antipsychotic that blocks dopamine receptors in the brain and reduces psychotic symptoms such as hallucinations, delusions, and paranoia.

- C: Incorrect. Decreased cholesterol is not an indication of chlorpromazine effectiveness, but rather a potential benefit that may occur due to its effect on lipid metabolism.

- D: Incorrect. Decreased esophageal reflux is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be avoided by taking the medication with food or water and avoiding lying down after administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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