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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Assisted living facilities are suitable for individuals who need assistance with activities of daily living but do not require skilled nursing care. This option might not be necessary based on the partner's exhaustion alone.
Choice B rationale:
Respite care provides temporary relief to caregivers, allowing them to take a break from their caregiving responsibilities. Given the partner's exhaustion, respite care would offer the much-needed rest, reducing caregiver burnout and ensuring better care for the client at home.
Choice C rationale:
Rehabilitation services are designed for patients who need specialized therapy after an illness or injury. While they might be beneficial for the client following a stroke, they do not directly address the partner's exhaustion and need for relief.
Choice D rationale:
Skilled nursing facilities provide 24/7 medical care for individuals with complex medical needs. The partner's exhaustion does not necessarily indicate the need for skilled nursing care, as the client's condition and care requirements were not provided in the scenario.
Correct Answer is A
Explanation
The adolescent has not voided in 4 hr.
Rationale:
- A. The nurse should not address the parents' concerns and provide education and support, but refer the concerns to the provider to address the concerns about the surgical procedure.
- B. The adolescent's blood pressure is 131/89 mm Hg. This is not a correct answer because this blood pressure is within the normal range for an adolescent and does not indicate any complications or adverse effects from the injury or medication.
- C. The adolescent reports severe pain. This is not a correct answer because the nurse should administer morphine as prescribed for pain relief, but this is not a priority finding that requires immediate intervention or reporting to the provider. The nurse should also monitor the adolescent's pain level and response to medication, and use nonpharmacological methods to reduce pain and anxiety.
- D.Although this may raise concerns about renal injury, it is no a contraindication or cause for delay for the emergency surgical procedure.
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