A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception?

The correct answer is Choice C.

Choice A rationale:

• While maintaining a distance of 3 feet can reduce the risk of direct contact transmission, it is not the most effective measure for contact isolation precautions.
• Contact isolation aims to prevent the spread of pathogens that can be transmitted through direct or indirect contact with the infected person or contaminated objects.
• A distance of 3 feet may not be sufficient to prevent transmission via droplets or fomites (inanimate objects that can harbor infectious agents).

Choice B rationale:

• Sterile gloves are not routinely required for contact isolation precautions.
• They are primarily used for sterile procedures or when there is a risk of exposure to blood or body fluids.
• For contact isolation, standard clean gloves are usually sufficient to protect against transmission via direct contact.

Choice C rationale:

• Leaving equipment that is used routinely in the client's room is a crucial part of contact isolation precautions.
• This practice prevents the spread of infection by minimizing the movement of potentially contaminated items outside of the isolation room.
• Equipment like stethoscopes, blood pressure cuffs, and thermometers should be dedicated to the client's use and not shared with other patients.

Choice D rationale:

• Negative-pressure airflow rooms are used for airborne isolation precautions, which are designed to prevent the spread of pathogens that can be transmitted through the air.
• Contact isolation does not specifically require a negative-pressure room, as the primary mode of transmission is through direct or indirect contact, not airborne particles.

d. Remove the IV catheter.

Explanation:

The correct answer is d. Remove the IV catheter.

If the nurse realizes that the incorrect IV solution is infusing, it is essential to take prompt action to prevent harm to the client. Removing the IV catheter is the appropriate course of action to stop the infusion of the incorrect solution.

Option a, completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.

Option b, allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.

Option c, documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.

By promptly removing the IV catheter, the nurse stops the infusion of the incorrect solution and prevents further harm to the client. Afterward, the nurse should assess the client for any adverse effects, inform the appropriate healthcare providers, and follow the facility's policies and procedures for reporting incidents and documenting the error.