A nurse is assisting in the admission of a client who has measles. Which of the following isolation precautions should the nurse initiate?

Contact.

Airborne.

Protective environment.

Droplet.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Contact precautions are indicated when the client has a condition that can be easily transmitted through direct contact with the client or their environment. Measles, which is an airborne disease, requires more stringent precautions due to its mode of transmission.
Choice B rationale:
The correct choice. Measles is spread through airborne particles, making airborne precautions necessary. These precautions include placing the client in a negative pressure room, wearing appropriate respiratory protection (e.g., N95 mask), and ensuring that healthcare providers are properly protected from inhaling infectious particles.
Choice C rationale:
A protective environment is a specialized form of isolation used for clients with compromised immune systems, such as those undergoing stem cell transplants. It involves maintaining a sterile environment to prevent the introduction of pathogens. This level of precautions is not applicable to clients with measles.
Choice D rationale:
Droplet precautions are appropriate for diseases that are transmitted through respiratory droplets generated by coughing, sneezing, or talking. Measles, however, is transmitted through smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions the most suitable choice.

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Correct Answer is B

Explanation

Choice A rationale:
Positioning the child sitting with their buttocks at the edge of the table is not appropriate for collecting a bone marrow specimen from a preschooler. This position does not provide adequate access to the bone marrow aspiration site and may lead to discomfort for the child.
Choice B rationale:
Placing the child in a prone position (lying face down) is suitable for collecting a bone marrow specimen from a preschooler. This position exposes the posterior iliac crest, which is a common site for bone marrow aspiration. It allows for easier access to the bone marrow and reduces the risk of injury.
Choice C rationale:
Positioning the child side-lying to expose the vertebrae is not the recommended position for bone marrow aspiration. The iliac crest, not the vertebrae, is the usual site for this procedure in children. Placing the child in a side-lying position would make it difficult to access the appropriate site.
Choice D rationale:
Placing the child supine with legs flexed outward into a frog-like position is suitable for collecting a bone marrow specimen. This position provides access to the iliac crest while allowing for better immobilization of the child. It also ensures the child's safety and comfort during the procedure.

A. Warm the skin prior to probe placement. B. Reposition the probe every 2 hr. C. Tape the wire to the palm of the hand. D. Apply the sensor to the index fingernail.

Correct Answer is B

Explanation

Answer: B. Reposition the probe every 2 hours.

Rationale:

A. Warm the skin prior to probe placement:While cold fingers can lead to inaccurate readings,warming the skin is not an essential step and is not routinely recommended in clinical practice.
B. Reposition the probe every 2 hours:This iscorrect.Continuous pressure from the probe in one spot can cause skin breakdown and pressure injuries.Repositioning the probe every 2 hours helps to prevent this and ensure accurate readings.
C. Tape the wire to the palm of the hand:This is incorrect.The pulse oximeter probe should be placed on a vascular site,such as a fingertip or earlobe.Taping the wire to the palm would not provide accurate readings.
D. Apply the sensor to the index fingernail:This is incorrect.The fingernail does not have sufficient blood flow for accurate pulse oximetry readings.The probe should be placed on the fleshy pad of the fingertip.

Therefore, the most important action for the nurse to take is to reposition the probe every 2 hours to prevent skin breakdown and ensure accurate readings.

Additional Points:

The nurse should also choose a clean and dry site for probe placement.
The probe should be snug but not too tight.
The nurse should monitor the child for signs of skin breakdown,such as redness,swelling,or pain.
If the child is restless or active,the nurse may need to secure the probe with additional tape or a special wrap.

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A nurse is assisting in the admission of a client who has measles. Which of the following isolation precautions should the nurse initiate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the collection of a bone marrow specimen from a preschooler. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a school-age child who has a new prescription for continuous pulse oximetry monitoring. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Answer: B. Reposition the probe every 2 hours.

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