A nurse is caring for a client on a medical-surgical unit.

Which of the following actions are part of the isolation precautions for this client?

Place the client in a room with positive airflow.

Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room.

When removing personal protective equipment, remove the gown first.

Provide a mask for the client when they are outside their room.

Don a gown when entering the client's room.

Answer and Explanation

Correct Answer : A,D,E

A. Place the client in a room with positive air flow: Placing the client in a room with positive air flow helps prevent the spread of infectious agents within the healthcare facility. This is particularly important for clients with airborne infections.

D. Provide a mask for the client when they are outside their room: Providing a mask for the client when they are outside their room helps prevent the spread of infectious agents to others if the client has a contagious respiratory infection.

E. Don a gown when entering the client's room: Wearing a gown upon entering the client's room helps protect the nurse from contact with the client's body fluids and reduces the risk of transmitting pathogens to other clients or healthcare workers.

B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room: Hand sanitizer is not a substitute for proper handwashing with soap and water. Hand sanitizer may be used in addition to handwashing, but it is not used with such a specific quantity.

C. When removing personal protective equipment, remove gloves first: When removing personal protective equipment, the correct sequence is to remove gloves, perform hand hygiene, and then remove other items such as gown, mask, and eyewear. This helps prevent contamination of the hands during the process.

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Correct Answer is A

Explanation

Choice A reason:
Increased night-time sleeping is the appropriate finding. As individuals age, it is common for their sleep patterns to change. Older adults often experience changes in their sleep duration, including increased night-time sleeping and daytime napping. This can be attributed to changes in circadian rhythm and other factors.
Choice B reason:
A heightened sense of pain is incorrect. Older adults may experience a decreased sensitivity to pain, known as hypoalgesia, due to changes in the nervous system.
Choice C reason:
Decreased sense of balance is incorrect. While changes in balance can occur with aging, they are not universal. Many older adults maintain good balance through exercise and other strategies.
Choice D reason:
Night-time urinary incontinence is incorrect. While some older adults may experience night-time urinary incontinence, it is not a universally expected finding and can be influenced by various factors, including overall health and lifestyle.

A. Place the wasted portion of the controlled substance in the sharp container. B. Ask a second nurse to record her signature when wasting any unused portion of the controlled substance. C. Verify the count total of the controlled substance after removing the amount needed. D. Report any discrepancy in the count total of the controlled substance after administration.

Correct Answer is C

Explanation

Choice A reason:
Placing the wasted portion of the controlled substance in the sharp container is not correct. Wasted controlled substances should be disposed of according to specific regulations and facility protocols.
Choice B reason:
Asking a second nurse to record her signature when wasting an unused portion of the controlled substance is not a standard practice. The process for wasting controlled substances usually involves following specific documentation procedures, but this does not necessarily require a second nurse's signature.
Choice C reason:
Verifying the count total of the controlled substance after removing the amount needed is the appropriate action. When administering a controlled substance, it is crucial to maintain accurate accountability of the medication. This includes verifying the count total of the controlled substance before and after removing the amount needed for administration. This step helps ensure proper documentation, prevent errors, and maintain appropriate control over controlled substances.
Choice D reason:
Reporting any discrepancy in the count total of the controlled substance after administration is important, but it should be done as a separate step from verifying the count total before administration. Discrepancies should be reported according to facility policy to ensure proper investigation and resolution.

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A nurse is caring for a client on a medical-surgical unit. Which of the following actions are part of the isolation precautions for this client?

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A nurse is caring for a client on a medical-surgical unit.

Which of the following actions are part of the isolation precautions for this client?