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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Answer: C

Rationale:

A) Encourage strength-training exercise: Strength-training exercises can be beneficial in building muscle mass and improving overall strength. However, for a client with leukemia experiencing chronic fatigue, this may be too strenuous and could exacerbate their fatigue rather than alleviate it. It is better to encourage light to moderate activities based on their tolerance.

B) Increase the client's fluids to 4 L per day: While adequate hydration is important, increasing fluids to 4 L per day may not be suitable for all clients and could pose risks, particularly if there are concerns about fluid balance or renal function. This recommendation should be tailored to the client's specific needs and medical condition.

C) Increase protein in the diet: Increasing protein in the diet can help improve energy levels and support the body's repair and regeneration processes. For clients with leukemia who are experiencing chronic fatigue, a high-protein diet can aid in maintaining muscle mass and overall nutritional status, helping to combat fatigue.

D) Encourage the client to have continual bed rest: Encouraging continual bed rest can lead to deconditioning and further exacerbate fatigue. It is important to balance rest with periods of gentle activity to maintain some level of physical function and avoid complications such as muscle atrophy or deep vein thrombosis.

A. Constipation B. Elevated skin patches C. Ringing in the ears D. Depression E. None F. None

Correct Answer is B

Explanation

Answer: B. Elevated skin patches

Rationale:

A. Constipation:
Constipation is not a typical adverse effect of cefazolin. Antibiotics generally cause gastrointestinal symptoms like diarrhea rather than constipation, so this is not a primary concern with cefazolin therapy.

B. Elevated skin patches:
Elevated skin patches may indicate an allergic reaction, such as hives or a rash, which can be a serious side effect of cefazolin. Allergic reactions to antibiotics can escalate quickly and may require immediate medical attention. Monitoring for and reporting any skin changes is important to prevent potential complications.

C. Ringing in the ears:
Tinnitus (ringing in the ears) is not commonly associated with cefazolin. This symptom is more frequently associated with certain other antibiotics, such as aminoglycosides, but is not a primary concern with cefazolin use.

D. Depression:
Depression is not a known side effect of cefazolin. While mood changes may be seen with some medications, cefazolin’s primary side effects are related to hypersensitivity reactions and gastrointestinal symptoms.

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A nurse is caring for a client who has been placed on contact isolation precautions. Which of the following interventions should the nurse implement?

Nursing Test Bank

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