A nurse is assisting a charge nurse with room assignments.
There is one private room available on the unit to accommodate a client who needs airborne precautions.Which client should be assigned to this room?

A client who has community-acquired pneumonia with copious respiratory secretions

A client who has AIDS and is coughing up blood

A client who has Guillain-Barré syndrome and is on a ventilator

A client who has bronchitis and a tracheostomy

Answer and Explanation

The Correct Answer is A

Choice A rationale
A client who has community-acquired pneumonia with copious respiratory secretions should be assigned to the private room. This is because pneumonia, especially with copious respiratory secretions, can be transmitted through the air, and therefore requires airborne precautions.
Choice B rationale
A client who has AIDS and is coughing up blood may not necessarily require a private room for airborne precautions. While AIDS is a serious condition, it is not primarily transmitted through the air. Instead, it is transmitted through direct contact with bodily fluids, particularly blood, semen, vaginal fluids, and breast milk.
Choice C rationale
A client who has Guillain-Barré syndrome and is on a ventilator would not necessarily require a private room for airborne precautions. Guillain-Barré syndrome is a neurological disorder, not an infectious disease, and it is not transmitted from person to person.
Choice D rationale

A client who has bronchitis and a tracheostomy may not necessarily require a private room for airborne precautions. While bronchitis can be caused by an infection, it is typically transmitted through direct contact or droplet transmission, not through the air.

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Correct Answer is A

Explanation

Choice A rationale
Vibration is a technique used in chest physiotherapy to increase the turbulence of the client’s exhaled air. It involves the use of manual or mechanical techniques to create vibrations in the chest wall during exhalation. This helps to loosen mucus in the airways and improve clearance of secretions.
Choice B rationale
Percussion, also known as chest clapping, is a technique used in chest physiotherapy to help loosen and mobilize secretions in the lungs. However, it does not specifically increase the turbulence of exhaled air.
Choice C rationale
Postural drainage involves positioning the client in specific ways to use gravity to assist in the removal of secretions from the lungs. While it can be beneficial in managing respiratory infections, it does not directly increase the turbulence of exhaled air.
Choice D rationale

Nebulization involves the use of a machine to create a mist of medication that the client inhales into the lungs. While it can be used to deliver medications to help manage respiratory infections, it does not increase the turbulence of exhaled air.

A. “I will call the doctor and get the prescription.”. B. “I will cover the catheter so he cannot see it.”. C. “Let me provide more stimulation in his environment.”. D. “Let’s wait until tonight to see if he continues this behavior.”.

Correct Answer is A

Explanation

Choice A rationale
The nurse should prioritize the safety of the patient. If a patient is frequently attempting to remove his feeding tube, it could lead to complications such as infection or injury. Therefore, the nurse might need to consider using a restraint as a last resort. However, it’s important to note that restraints should only be used when all other alternatives have been explored and failed. These alternatives include having staff or a family member sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications.
Choice B rationale
Covering the catheter so the patient cannot see it might not be effective if the patient is aware of its presence and is determined to remove it. This approach does not address the underlying issue and may not prevent the patient from attempting to remove the feeding tube.
Choice C rationale
Providing more stimulation in the patient’s environment might be helpful in some cases, but it may not prevent the patient from attempting to remove the feeding tube. The effectiveness of this approach would depend on the specific circumstances and the patient’s condition.
Choice D rationale
Waiting until tonight to see if the patient continues this behavior could potentially put the patient at risk. If the patient is frequently attempting to remove the feeding tube, immediate action may be necessary to ensure the patient’s safety.

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A nurse is assisting a charge nurse with room assignments. There is one private room available on the unit to accommodate a client who needs airborne precautions.Which client should be assigned to this room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing chest physiotherapy on a client with a respiratory infection. Which technique should the nurse use to increase the velocity and turbulence of the client’s exhaled air?

Correct Answer is A

Explanation

A nurse is caring for a patient who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?

Correct Answer is A

Explanation

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A nurse is assisting a charge nurse with room assignments.
There is one private room available on the unit to accommodate a client who needs airborne precautions.Which client should be assigned to this room?