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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 A

Explanation

The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.

Explanation for the other options:

b) Document the client's risk in the medical record: While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.

c) Request a referral for physical therapy: Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.

d) Place a gait belt in the client's room: Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.

A. Monitor the client's vital signs every 8 hours B. Reposition the endotracheal tube every 12 hours. C. Place the client in a supine position. D. Perform oral care every 2 hours

Correct Answer is D

Explanation

Performing oral care every 2 hours is an important nursing intervention for a client receiving mechanical ventilation via an endotracheal tube. This helps to reduce the risk of ventilator-associated pneumonia.

a) Monitoring the client's vital signs is important, but it should be done more frequently than every 8 hours.

b) Repositioning the endotracheal tube is not necessary unless there is a specific indication.

c) Placing the client in a supine position is not recommended as it increases the risk of aspiration.

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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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