A nurse is assisting with planning care for a client who was admitted for reports of severe coughing, night sweats, and blood in the sputum. Which of the following precautions should the nurse take?
Place the client in a negative-pressure airflow room.
Wear a surgical mask when entering the client's room.
Have a container for soiled linens outside the client's door.
Remain within 91.4 cm (3 ft) of the client.
The Correct Answer is A
A. Place the client in a negative-pressure airflow room: This is correct as these symptoms are indicative of tuberculosis (TB), which requires airborne precautions. A negative-pressure room helps to prevent the spread of airborne pathogens.
B. Wear a surgical mask when entering the client's room: This is incorrect because a surgical mask does not provide adequate protection against airborne particles; an N95 respirator is necessary for airborne precautions.
C. Have a container for soiled linens outside the client's door: This is incorrect as soiled linens should be handled and disposed of within the room under appropriate infection control protocols, not just placed outside.
D. Remain within 91.4 cm (3 ft) of the client: This is incorrect as maintaining this distance does not prevent the spread of airborne diseases. Proper airborne precautions, including the use of personal protective equipment, are necessary.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "You will not become fatigued when you use assistive devices": This is incorrect as clients may still experience fatigue even with assistive devices, and energy conservation strategies should be discussed.
B. "Plan to hire a home care aide to perform all of your ADLs": This is not advisable as the goal is to encourage as much independence as possible; assistance should be provided based on need, not all tasks.
C. "Install grab bars in your shower to assist with your balance": This is correct as installing grab bars can enhance safety and support the client’s balance, helping to prevent falls and injuries.
D. "Place a towel in the shower to prevent slipping": This is not as effective as grab bars and may not provide adequate support or prevent slips as well as proper bathroom modifications.
Correct Answer is D
Explanation
A. "My urine comes out whenever I sneeze": This indicates stress incontinence, where urine leakage occurs with physical activities that increase abdominal pressure.
B. "It seems like my bladder empties without warning": This suggests urge incontinence, characterized by a sudden and intense urge to urinate.
C. "I have urine incontinence whenever I take a diuretic": This statement is more related to the effects of diuretics rather than a specific type of urinary incontinence.
D. "My urine seems to dribble out frequently": This is characteristic of overflow incontinence, where the bladder becomes overfilled and urine dribbles out due to inadequate emptying.
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