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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Decrease daily oral fluid intake. Rationale: This choice is not appropriate for a client experiencing a vaso-occlusive crisis in sickle cell anemia. In this crisis, there is a risk of dehydration due to increased fluid loss, and decreasing oral fluid intake would exacerbate this issue. Adequate hydration is important to prevent further sickling of red blood cells and maintain organ perfusion.
Choice B rationale:
Maintain bed rest to prevent hypoxemia. Rationale: This is the correct choice. During a vaso-occlusive crisis in sickle cell anemia, blood flow to certain tissues is restricted, leading to tissue hypoxia and pain. Bed rest is recommended to reduce metabolic demands and oxygen consumption, helping to prevent further tissue damage and improve oxygenation. It also reduces the risk of complications such as thrombosis and respiratory compromise.
Choice C rationale:
Apply cold compresses to painful joints. Rationale: Applying cold compresses is not a recommended intervention for vaso-occlusive crisis in sickle cell anemia. Cold can exacerbate vasoconstriction and further compromise blood flow to the affected tissues. Warm compresses or warm baths might be more appropriate to promote vasodilation and alleviate pain.
Choice D rationale:
Administer meperidine to eliminate a fever. Rationale: Administering meperidine solely to eliminate a fever is not the primary focus of care for a vaso-occlusive crisis. The priority is to manage pain and improve tissue perfusion. Meperidine is an opioid analgesic that can be used to manage severe pain associated with sickle cell crises, but it should be given with caution due to the risk of respiratory depression and the potential for addiction.
Correct Answer is B
Explanation
Choice A rationale:
Urine osmolality 500 mOsm/kg. Urine osmolality is a measure of urine concentration and is not a reliable indicator of infection. It reflects the kidney's ability to concentrate urine and can vary based on hydration status and other factors. An elevated urine osmolality could suggest dehydration, not necessarily infection.
Choice B rationale:
WBC 17,500/mm3. This is the correct choice. An elevated white blood cell count (WBC) is a hallmark sign of infection. The body's immune response to an infection often includes an increase in WBC count, particularly the neutrophil count. This elevation is known as leukocytosis and is a red flag for infection.
Choice C rationale:
BUN 12 mg/dL. Blood Urea Nitrogen (BUN) measures kidney function and hydration status. While an elevated BUN can indicate dehydration, it is not a specific marker for infection. BUN levels can be influenced by various factors, including diet and renal function.
Choice D rationale:
Urine specific gravity 1.014. Urine-specific gravity reflects the concentration of solutes in urine and the kidney's ability to concentrate or dilute urine. While changes in urine specific gravity can indicate dehydration or overhydration, it is not a direct indicator of infection. An infection is better detected through changes in WBC count and other clinical signs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.