A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?
Wear gloves when entering the client's room.
Encourage the client to ambulate in the hall.
Wear an N95 respirator mask.
Provide a positive pressure airflow room.
The Correct Answer is C
A. Gloves are not specifically required for airborne precautions unless contact with infectious secretions or materials is anticipated. Airborne precautions primarily focus on preventing inhalation of infectious droplet nuclei. Therefore, wearing gloves is not necessary solely due to airborne precautions.
B. This option is not related to airborne precautions. Encouraging ambulation in the hall is a general nursing intervention and does not specifically address preventing the transmission of airborne pathogens.
C. An N95 respirator mask is designed to filter out 95% of airborne particles, including those containing infectious agents. It provides respiratory protection for healthcare workers who may be exposed to airborne pathogens during procedures such as aerosol-generating procedures (e.g., suctioning, bronchoscopy) or when caring for clients with airborne infections.
D. Positive pressure airflow rooms are typically used for clients requiring protective isolation (e.g., immunocompromised clients) but are not specifically required for clients on airborne precautions. Negative pressure airflow rooms are preferred for clients on airborne precautions because they prevent the spread of airborne pathogens to other areas of the facility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This instruction is incorrect for a 24-hour urine collection. During a 24-hour urine collection, the client should urinate into a designated collection container at the start of the collection period and continue to collect all urine voided over the next 24 hours. The nurse should instruct the client to empty their bladder completely at the end of the 24-hour period into the same container used throughout the collection period. This ensures that all urine produced over the 24 hours is included in the specimen.
B. Discarding the first urine voided at the beginning of the collection period is a common instruction for some types of urine tests, such as for urinary catecholamines or specific timed collections. However, for a 24-hour urine collection, the client should start collecting urine from the very first void and include all subsequent urine produced over the next 24 hours.
C. This instruction is incorrect for a 24-hour urine collection. All urine produced during the 24-hour period should be saved in a single designated collection container. Using separate containers for each void would make it difficult to accurately measure the total volume of urine collected over the specified time frame.
D. Storing the urine collection container at room temperature is generally appropriate for a 24-hour urine collection. This helps maintain the stability of the urine sample and ensures accurate test results. Refrigeration may be required if specified by the healthcare provider for specific tests, but this should be clearly communicated to the client if necessary.
Correct Answer is A
Explanation
A. Clean gloves should be worn when entering the room of a client with MRSA to prevent contact transmission of the bacteria. Gloves should be put on before any contact with the client or potentially contaminated surfaces and should be removed and disposed of properly after leaving the room.
B. A surgical mask is generally not necessary for routine care of a client with MRSA unless there is a risk of splashes or sprays of bodily fluids. The main mode of transmission for MRSA is contact, so gloves are the primary protective measure.
C. Sterile gloves are typically not required unless performing sterile procedures directly involving the wound or handling sterile equipment. For routine assessment of the client's pulse, clean gloves are sufficient.
D. Protective eyewear is not necessary for routine care such as checking a client's pulse. It is primarily used when there is a risk of splashes or sprays that could potentially reach the eyes.
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