A nurse is caring for a client who has been placed on contact isolation precautions. Which of the following interventions should the nurse implement?
Inform visitors to remain at least 3 feet away from the client.
Apply sterile gloves when entering the client's room.
Leave all equipment that is used routinely in the client's room
Place the client in a negative-pressure airflow room
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale:
- While maintaining a distance of 3 feet can reduce the risk of direct contact transmission, it is not the most effective measure for contact isolation precautions.
- Contact isolation aims to prevent the spread of pathogens that can be transmitted through direct or indirect contact with the infected person or contaminated objects.
- A distance of 3 feet may not be sufficient to prevent transmission via droplets or fomites (inanimate objects that can harbor infectious agents).
Choice B rationale:
- Sterile gloves are not routinely required for contact isolation precautions.
- They are primarily used for sterile procedures or when there is a risk of exposure to blood or body fluids.
- For contact isolation, standard clean gloves are usually sufficient to protect against transmission via direct contact.
Choice C rationale:
- Leaving equipment that is used routinely in the client's room is a crucial part of contact isolation precautions.
- This practice prevents the spread of infection by minimizing the movement of potentially contaminated items outside of the isolation room.
- Equipment like stethoscopes, blood pressure cuffs, and thermometers should be dedicated to the client's use and not shared with other patients.
Choice D rationale:
- Negative-pressure airflow rooms are used for airborne isolation precautions, which are designed to prevent the spread of pathogens that can be transmitted through the air.
- Contact isolation does not specifically require a negative-pressure room, as the primary mode of transmission is through direct or indirect contact, not airborne particles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. Perform passive range-of-motion exercises.
During a vaso-occlusive crisis in sickle-cell disease, blood flow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiffness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.
Explanation for the other options:
a. Limit fluid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood flow. Restricting fluid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage fluid intake unless otherwise instructed by the healthcare provider.
c. Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood flow to affected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.
d. Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.
In summary, performing passive range-of-motion exercises is an appropriate intervention to include in the
plan of care for a school-age child experiencing a vaso-occlusive crisis in sickle-cell disease.
Correct Answer is D
Explanation
a. Oil-based lubricant
Explanation:
The correct answer is a. Oil-based lubricant.
When preparing to insert a nasogastric tube for gastric decompression, the nurse should obtain an oil- based lubricant. Lubricating the nasogastric tube before insertion helps facilitate smooth passage through the nasal passages and into the stomach, reducing discomfort and potential trauma to the client.
Option b, an enteric feeding pump, is not necessary for the insertion of a nasogastric tube for gastric decompression. An enteric feeding pump is used for administering enteral feedings, which is a different procedure and indication
Option c, sterile gloves, may be needed depending on the facility's policy and the specific circumstances of the client. While maintaining aseptic technique is important during the procedure, sterile gloves may not always be required for nasogastric tube insertion. Clean gloves or a clean hand hygiene practice may be sufficient in some cases.
Option d, pH strips, are not typically needed for nasogastric tube insertion for gastric decompression. pH strips are more commonly used to check the acidity or alkalinity of body fluids, such as gastric aspirate, to confirm placement of the nasogastric tube in the stomach.
By obtaining an oil-based lubricant, the nurse ensures the appropriate preparation for the nasogastric tube insertion, promoting the client's comfort and safety during the procedure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today