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. Give directions using simple phrases.
The correct answer is b. Give directions using simple phrases.
Explanation:
When assisting with the plan of care for a client with Alzheimer's disease, it is important to consider their cognitive impairments and provide appropriate interventions. Giving directions using simple phrases is recommended because it helps the client beter understand and follow instructions. Complex or lengthy directions can be confusing and overwhelming for individuals with Alzheimer's disease. Using clear and concise language can enhance communication and facilitate the client's ability to engage in activities of daily living.
Explanation for the other options:
a. Encourage the client to talk about current events: While social interaction and engagement are beneficial for clients with Alzheimer's disease, their ability to comprehend and discuss current events may be limited due to cognitive impairments. It is important to adapt communication to the client's cognitive abilities and interests.
c. Orient the client to time and place twice per day: Frequent orientation to time and place can be helpful for clients with Alzheimer's disease, but the specific frequency should be based on the individual's needs and preferences. Some individuals may require more frequent orientation, while others may find it overwhelming. The plan of care should be individualized to address the client's specific needs.
d. Rotate assistive personnel to help the client with ADLs: Consistency and familiarity are important for individuals with Alzheimer's disease. Rotating assistive personnel frequently may disrupt the client's routine and cause increased confusion and agitation. Whenever possible, it is best to maintain a consistent caregiving team to provide familiarity and establish a therapeutic relationship with the client.
In summary, giving directions using simple phrases is an appropriate action when assisting with the plan of care for a client with Alzheimer's disease. This approach promotes effective communication and enhances the client's ability to understand and follow instructions.
Correct Answer is B
Explanation
The correct answer is b. "I will apply petroleum jelly to the penis with each diaper change."
Choice A rationale:
- It is incorrect to focus on removing all yellow exudate.A small amount of yellow exudate is normal during the healing process after circumcision.Attempting to aggressively clean it off can irritate the delicate healing tissues and cause discomfort for the baby.
- Instead,parents should gently cleanse the area with warm water during diaper changes,allowing any mild exudate to naturally drain.
Choice B rationale:
- Applying petroleum jelly with each diaper change is an essential step in promoting healing and preventing discomfort after circumcision.Here's why:
- Protects against moisture:Petroleum jelly forms a barrier that protects the delicate healing tissues from moisture from urine and feces.This helps to prevent irritation and keeps the area clean.
- Reduces friction:The lubricating properties of petroleum jelly reduce friction between the penis and the diaper,which can minimize discomfort and pain for the baby.
- Promotes healing:Petroleum jelly creates a moist environment that promotes healing and reduces scab formation.This helps the circumcision site to heal faster and more comfortably.
Choice C rationale:
- While ensuring a proper diaper fit is important for overall hygiene,it's not the most crucial aspect of post-circumcision care.A snug diaper can put unnecessary pressure on the healing penis,potentially causing irritation and discomfort.It's generally recommended to choose a diaper that fits comfortably without being too tight.
Choice D rationale:
- Using soap to wash the penis is not recommended during the healing process.Soap can be harsh and drying to the delicate tissues,potentially causing irritation and delaying healing.
- Warm water is sufficient for cleansing the area during diaper changes.
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