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.
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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Related Questions
Correct Answer is B
Explanation
A. Contact precautions are not necessary for hepatitis C unless there is visible contamination of the environment with blood.
B. Hepatitis C is spread primarily through blood-to-blood contact, so the nurse should implement standard precautions, which include wearing gloves and other protective barriers as necessary.
C. Droplet precautions are used for infections spread by respiratory droplets, not for hepatitis C.
D. Airborne precautions are used for diseases that spread through airborne particles, such as tuberculosis.
Correct Answer is B
Explanation
A. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.
B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.
C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.
D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.
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