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:
The client has expressed a lack of understanding about the procedure, which indicates that they may not have received sufficient information or clarification. It is important to notify the provider so they can ensure the client fully understands the procedure before giving informed consent.
Choice B reason:
The nurse should provide basic information and answer questions within their scope, but detailed explanations about the procedure are best provided by the provider who is performing the surgery.
Choice C reason:
While brochures can be helpful, they do not replace the need for direct, clear communication with the healthcare provider about the specific details of the surgery.
Choice D reason:
An incident report is not necessary in this context as the situation is related to informed consent and not an error or safety issue.
Correct Answer is D
Explanation
A. Develop a plan for the client to integrate the change into her lifestyle: Developing a plan for integrating change into one's lifestyle is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the focus is on considering change rather than developing a detailed plan.
B. Assist the client in setting goals to make the change: Setting specific goals is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the client is not yet ready to commit to specific goals.
C. Recommend small changes for the client to make to change her behavior over time: During the contemplation stage of health behavior change, clients are considering making a change but are not yet committed to taking immediate action. This is also more suitable for the preparation or action stages.
D. In the contemplation stage, the client is aware of the problem and is considering making a change but has not yet committed to action. Providing information about the benefits can help the client move toward the next stage of change.
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