A nurse is assisting in the review of infection control precautions implemented by staff in a facility.
Select 2 client situations that require follow-up by the infection control nurse.
Client 1
Client 2
Client 3
Client 4
Client 5
Correct Answer : A,D
A. Client 1: The client with Pertussis should have individuals wear surgical masks when within 3 feet of the client, not 1 foot. Pertussis is highly contagious, and proper precautions are necessary to prevent transmission
B. Client 2: The client with Clostridium difficile is placed in a private room, and nurses wear gowns and gloves during direct care. These are appropriate contact precautions for preventing the spread of C. difficile.
C. Client 3: The client with Herpes simplex is managed with nurses wearing gowns and gloves during direct care, which is appropriate for preventing the spread of the virus through direct contact.
D. Client 4: The client with Mycobacterium tuberculosis should be placed in a negative airflow room, not a positive airflow room. Negative airflow rooms help contain airborne pathogens and prevent them from spreading to other areas.
E. Client 5: The client with Streptococcal pharyngitis is placed in a private room, and the client wears a surgical mask when transported outside their room. These are appropriate droplet precautions to prevent the spread of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Removing gloves before leaving an isolation room is appropriate practice and helps prevent the spread of infection.
B. Filling a basin with water at 40° C (104° F) is too hot for foot care and could lead to burns or injury; water temperature for foot care should be comfortably warm, typically around 37°C (98.6°F).
C. Instructing a client to look down at their feet when being assisted to ambulate is a safety measure that can help the client maintain balance and avoid tripping.
D. Applying water-soluble lubricant to the nares of a client receiving oxygen is a standard practice to prevent dryness and does not require intervention.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}
Explanation
Rationale
- Client 1: Red tag. This client has a significant loss of blood and a low heart rate, indicating they are in critical condition and need immediate intervention to survive.
- Client 2: Yellow tag. This client has second-degree burns and is in pain, but their condition is stable and not immediately life-threatening.
- Client 3: Black tag. This client is unresponsive with multiple severe burn injuries and Cheyne-Stokes respirations, indicating a very poor prognosis and unlikely survival.
- Client 4: Red tag. This client is experiencing severe chest pain and shortness of breath, which could indicate a life-threatening condition such as a heart attack and requires immediate attention.
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