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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 B

Explanation

Answer: B. Stiff posture

Rationale:
A. Lip-smacking : Lip-smacking is not typically an indication of pain in newborns. It may be associated with hunger or neurological responses, but it does not directly indicate discomfort or pain caused by shoulder dystocia or other injuries.
B. Stiff posture : A stiff posture can indicate pain in newborns, as they often exhibit hypertonicity or rigidity when experiencing discomfort. This response is a protective mechanism and may suggest the newborn is reacting to pain from potential nerve or tissue damage caused by shoulder dystocia.
C. Weak cry : While a weak cry may indicate neurological or respiratory distress, it is not a specific sign of pain. In the context of shoulder dystocia, a weak cry could reflect complications such as brachial plexus injury but does not directly signify the presence of pain.
D. Tongue-darting : Tongue-darting is more commonly associated with neurological issues or feeding difficulties rather than pain. It is not a typical behavioral response to discomfort or injury in newborns experiencing complications like shoulder dystocia.

A. Suggest the family persuade the client to take the medication. B. Recommend that the medication be delivered intramuscularly. C. Remind the newly licensed nurse that the client has a right to refuse medication. D. Suggest the newly licensed nurse contact the pharmacy to inquire about compatible foods.

Correct Answer is C

Explanation

The charge nurse should remind the newly licensed nurse that the client has a right to refuse medication. It is important for healthcare providers to respect the autonomy and rights of their clients, including the right to refuse treatment.

Option a is incorrect because it may not be appropriate for the family to persuade the client to take medication against their wishes.

Option b is incorrect because delivering medication intramuscularly against the client's wishes would violate their right to refuse treatment.

Option d is incorrect because inquiring about compatible foods with the pharmacy would not address the issue of the client's right to refuse medication.

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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

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should identify which of the following findings as an indication of pain?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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