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
Explanation
Choice A reason:
When preparing to insert an IV catheter, placing the tourniquet abovethe proposed insertion site helps facilitate venous distension and makes it easier to locate a suitable vein for the catheter insertion. This technique helps to improve visibility and access to the vein.
Choice B reason:
Placing the extremity in a dependent position (lower than the heart) can increase venous pressure and make it more difficult to insert the catheter.
Choice C reason:
Choosing the most proximal site on the extremity is not always necessary or appropriate. Veins distal to the proposed insertion site should be considered first, as they tend to be smaller and less accessible.
Choice D reason:
Applying a cool compress is not typically done before IV catheter insertion. It might cause vasoconstriction and make it more difficult to access a suitable vein.
Correct Answer is A
Explanation
Choice A reason:
A. Dilated pupils
During the alarm reaction stage of the general adaptation syndrome (GAS), the body's initial response to stress triggers the "fight or flight" response. This response is characterized by the release of stress hormones, increased sympathetic nervous system activity, and various physiological changes to prepare the body to respond to the stressor. Dilated pupils are one of the manifestations of the fight or flight response, allowing for improved visual acuity and awareness of the environment.
Choice B reason:
Physical exhaustion is inappropriate. This is typically associated with the exhaustion stage of GAS, which follows the alarm reaction stage.
Choice C reason:
Bradycardia is inappropriate. Bradycardia (slow heart rate) is not a typical manifestation during the alarm reaction stage. Increased heart rate (tachycardia) is more common during this stage.
Choice D reason:
Depression is inappropriate. Depression is not a direct manifestation of the alarm reaction stage. It is a psychological response that may occur during or after prolonged stress and may be associated with the later stages of GAS.
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