A nurse is assisting with the admission of a client who has leukemia. Which of the following transmission precautions should the nurse implement?
Droplet
Protective environment
Airborne
Contact
The Correct Answer is B
Choice A reason: Droplet precautions are necessary when dealing with infectious agents that are spread through large droplets expelled during coughing, sneezing, or talking. However, leukemia itself is not an infectious disease but a type of cancer affecting the blood and bone marrow. Therefore, droplet precautions are not typically required for leukemia patients unless they have a concurrent infection that warrants such measures.
Choice B reason: A protective environment refers to room designs that minimize the risk of infection in immunocompromised patients, such as those with leukemia. This includes HEPA filtration, positive air pressure rooms, and rigorous infection control practices. Given that patients with leukemia have compromised immune systems, a protective environment is crucial to protect them from infections, which can be life-threatening due to their reduced ability to fight off diseases.
Choice C reason: Airborne precautions are used for diseases that are transmitted through tiny droplets that remain suspended in the air and can be inhaled by others. Diseases like tuberculosis, measles, and chickenpox require airborne precautions. Leukemia does not require airborne precautions unless the patient has a coexisting airborne infection.
Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. While leukemia patients may be more susceptible to infections due to their compromised immune systems, contact precautions are not specifically required for leukemia itself but may be necessary if the patient has a concurrent contact-transmissible infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Cleaning the incision with soap and water is not typically recommended as it can disrupt the healing process and may lead to irritation or infection. The incision should be kept clean and dry, and any cleaning should be done according to the surgeon's instructions.
Choice B reason: Performing hand hygiene before dressing changes is essential in preventing incisional infections. Hand hygiene is one of the most effective ways to prevent the spread of infections, including those at surgical sites.
Choice C reason: Protective isolation is used for immunocompromised patients to protect them from infections, not typically for postoperative patients unless they are at high risk for infection due to other conditions.
Choice D reason: Allowing the wound to air can be part of the healing process, but it must be done carefully and under the guidance of healthcare professionals to ensure that the wound is protected from contamination.
Correct Answer is A
Explanation
The correct answer is: a. Edema.
Choice A: Edema
Edema is swelling caused by excess fluid trapped in the body’s tissues. It is a common sign of inflammation and infection. When a wound becomes infected, the body’s immune response can cause increased fluid accumulation in the affected area, leading to noticeable swelling. This swelling is often accompanied by redness, warmth, and pain, which are classic signs of infection.
Choice B: Petechiae
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not typically associated with wound infections but rather with conditions that cause bleeding or clotting disorders. Petechiae do not indicate an infection but rather a different underlying issue that may require further investigation.
Choice C: Urticaria
Urticaria, also known as hives, is a skin reaction that causes itchy welts. It is usually a result of an allergic reaction and is not a sign of wound infection. Urticaria is characterized by raised, red, itchy bumps on the skin and does not typically occur in response to an infected wound.
Choice D: Crusting over granulated tissue
Crusting over granulated tissue is a normal part of the wound healing process. Granulation tissue forms as the wound heals, and a crust or scab may develop over it to protect the new tissue underneath. This is not an indication of infection but rather a sign that the wound is progressing through the healing stages.
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