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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The oral mucosa, especially the lips and tongue, is a reliable indicator of central cyanosis. Cyanosis is evident as bluish discoloration in these areas due to the presence of deoxygenated hemoglobin.
B. Cyanosis is less reliably visible on the eyelids compared to the lips and oral mucosa. Skin over the eyelids is typically thinner, but detection of cyanosis here can be more challenging due to variations in skin pigmentation and thickness.
C. Similar to the eyelids, cyanosis may be less evident on the ear lobes compared to the lips and oral mucosa. Ear lobes are less vascular and may not consistently show cyanosis unless the condition is severe.
D. The tip of the nose is another area where cyanosis can be detected, although it is less reliable than the lips and oral mucosa. Like the eyelids and ear lobes, the detection of cyanosis here can vary depending on individual skin characteristics.

A. There appears to be persistent reddening of the skin. B. There is a fluid-filled area under the skin. C. There is full-thickness skin loss with a crater. D. There is slough on part of the wound area.

Correct Answer is C

Explanation

A. This description is more indicative of a stage 1 pressure ulcer, where the skin is intact but shows non- blanchable redness. Stage 1 ulcers do not involve skin loss.
B. This description might indicate a stage 2 pressure ulcer, where there is partial-thickness skin loss involving the epidermis and/or dermis. Stage 2 ulcers are characterized by shallow open ulcers with a red- pink wound bed, without slough.
C. This description accurately defines a stage 3 pressure ulcer. Stage 3 ulcers involve full-thickness skin loss where adipose (fat) tissue may be visible, but deeper structures such as muscle, tendon, and bone are not exposed.
D. Slough refers to yellow, tan, gray, green, or brown necrotic tissue in the wound bed that must be removed to facilitate wound healing. Slough can be present in both stage 3 and stage 4 pressure ulcers, where stage 4 involves full-thickness skin loss with exposure of muscle, bone, or supporting structures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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