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 D
Explanation
Choice A reason:
Attaching the drainage bag to the side rails of the bed can create tension on the catheter and increase the risk of trauma or dislodgment.
Choice B reason:
Emptying the drainage bag when it is three-quarters full is appropriate to prevent the bag from becoming too heavy and pulling on the catheter. However, this is a practice for maintaining bag weight, not part of the overall care plan.
Choice C reason:
Taping the catheter to the lower abdomen is not recommended. Taping the catheter can cause irritation, tension, and skin breakdown, increasing the risk of infection and trauma to the urethra. The catheter should be secured to the thigh using a catheter securement device if necessary.
Choice D reason:
Keeping the drainage bag below the level of the bladder is the correct recommendation. When caring for a client with an indwelling urinary catheter, it is important to maintain proper catheter and drainage bag positioning to prevent complications. Keeping the drainage bag below the level of the bladder helps promote the free flow of urine, prevent reflux of urine into the bladder, and minimize the risk of urinary tract infections.
Correct Answer is C
Explanation
Choice A reason:
A blood glucose level of 110 mg/dl: A slightly elevated blood glucose level could be expected in response to enteral feeding.
Choice B reason:
Diarrhea one time in a 24-hour period is incorrect. Diarrhea can occur as a side effect of enteral feeding due to changes in the digestive process.
Choice C reason:
An unexpected finding when a client is receiving continuous enteral feeding via an NG tube is a rapid and significant weight gain of 0.91 kg (2 lb) in just 2 days. This could indicate fluid overload, which might be caused by excessive fluid intake or inadequate fluid removal by the body. Rapid weight gain should be assessed and reported as it could be a sign of underlying issues that need to be addressed.
Choice D reason:
A gastric residual of 300 mL at the end of the shift is incorrect. Gastric residuals can fluctuate during continuous enteral feeding, and a residual of 300 mL may not necessarily be unexpected depending on the client's overall condition and the healthcare provider's guidelines.
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