A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

Place the client in a room with negative airflow.

Wear a gown when providing care to the client.

Ensure the client's room has HEPA filtration.

Wear a mask when providing care to the client.

Answer and Explanation

The Correct Answer is D

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

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Correct Answer is B

Explanation

A. Elevating the head of the bed no more than 30° (not 45°) is recommended to avoid pressure on the sacrum and reduce the risk of developing pressure ulcers.

B. Using a transfer device helps to reduce friction and shear, which can prevent further damage to the skin, especially in clients at risk for pressure ulcers.

C. Cornstarch should not be applied to sensitive skin areas due to the risk of skin irritation and fungal growth.

D. Massaging bony prominences can cause tissue damage and should be avoided, as it increases the risk of skin breakdown.

A. Dorsal surface of the foot B. Conjunctivae C. Dorsal surface of the hand D. Pinnae of the ears

Correct Answer is B

Explanation

A. The dorsal surface of the foot and the dorsal surface of the hand are less reliable areas to assess for cyanosis in dark-skinned individuals.

B. Cyanosis in clients with dark skin can be more difficult to detect in the skin but is often visible in the conjunctivae of the eyes, as it reflects the oxygenation status of the blood.

C. The dorsal surface of the hand is also not an ideal area for assessing cyanosis in dark skin.

D. The pinnae of the ears can show signs of cyanosis but may not be as reliable as the conjunctivae, especially in dark-skinned individuals.

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A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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