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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason:
Supplemental oxygen supplies are correct. Seizures can sometimes cause a decrease in oxygen levels, so having supplemental oxygen available can help support the client's respiratory needs.
Choice B reason:
Limb restraints are incorrect. Limb restraints are not typically used for seizure precautions as they can be dangerous and restrict the client's movement, potentially causing harm during a seizure.
Choice C reason:
Oral suction equipment is correct. Seizures can be associated with excessive saliva or potential vomiting, so having oral suction equipment ready can help clear the airway if necessary.
Choice D reason:
The oral airway is incorrect. Inserting an oral airway is not a standard part of seizure precautions and should only be used by healthcare professionals with proper training.
Choice E reason:
The blood glucose monitor is correct. Monitoring blood glucose levels can be important, especially if the client takes antiepileptic medications that may affect blood sugar levels.
Correct Answer is A
Explanation
Choice A reason:
Discarding the needle in a puncture-proof container is the correct action to be taken. After administering an injection, the nurse should immediately dispose of the needle in a puncture-proof container. This helps prevent needlestick injuries and ensures proper disposal of sharp objects.
Choice B reason:
Removing the needle from the syringe is inappropriate because it could increase the risk of a needlestick injury. Needles should be discarded as a unit with the syringe.
Choice C reason:
Placing the needle on the bedside table is not a safe practice and can lead to accidental needlestick injuries.
Choice D reason:
Recapping the needle before disposal is not recommended, as it increases the risk of needlestick injuries. Many healthcare organizations discourage recapping due to the potential for accidental needle sticks. If recapping is required by local policy, it should be done using a safe method.
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