A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Contact

Airborne

Droplet

Protective

Answer and Explanation

The Correct Answer is D

A) Contact: While contact precautions are important for preventing the transmission of infections, they primarily apply to clients with known or suspected infections that can spread through direct or indirect contact with the client or their environment. Protective isolation goes beyond contact precautions and involves comprehensive measures to protect immunocompromised clients from all potential sources of infection.

B) Airborne: Airborne precautions are necessary for clients with infections that spread through the airborne route, such as tuberculosis or measles. While respiratory infections can pose a significant risk to immunocompromised clients, the focus of care for clients after hematopoietic stem-cell transplant is on preventing all types of infections, not just airborne ones.

C) Droplet: Droplet precautions are used for infections transmitted through respiratory droplets expelled when a person coughs, sneezes, or talks, such as influenza or pertussis. While respiratory infections are a concern for immunocompromised clients, the broader approach of protective isolation is more appropriate for clients after hematopoietic stem-cell transplant, as it encompasses all potential routes of infection transmission, not just droplet spread.

D) Protective: Clients who have undergone allogeneic hematopoietic stem-cell transplant are profoundly immunocompromised due to the destruction of their immune system and are highly susceptible to infections. Protective isolation, also known as reverse isolation, is necessary to minimize the risk of infection in these clients. This includes implementing strict infection control measures such as wearing gowns, gloves, masks, and sometimes goggles to prevent exposure to pathogens. Additionally, maintaining a clean environment and limiting visitors and healthcare personnel who may carry infectious agents are essential components of protective isolation.

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Correct Answer is A

Explanation

A. Turn the client on his side before starting oral care: This is the correct action. Turning the client on their side helps prevent aspiration of oral secretions or fluids during oral care, especially for an immobile client who may have difficulty swallowing or managing oral secretions effectively. Positioning the client on their side also facilitates better access to the oral cavity for oral care procedures.

B. Use the thumb and index finger to keep the client's mouth open: Using the thumb and index finger to keep the client's mouth open may cause discomfort or injury to the client. Instead, it's essential to encourage the client to open their mouth gently or use an appropriate oral device to keep the mouth open during oral care.

C. Apply petroleum jelly to the client's lips after oral care: Applying petroleum jelly to the client's lips after oral care can help keep the lips moisturized and prevent dryness. However, it is not the most immediate action necessary for oral care. Ensuring proper positioning and cleaning of the oral cavity take precedence during oral care for an immobile client.

D. Use a stiff toothbrush to clean the client's teeth: Using a stiff toothbrush can cause damage to the client's oral tissues, especially if the client has impaired oral hygiene or compromised oral health. It's essential to use a soft-bristled toothbrush or sponge swabs for oral care to prevent injury or trauma to the oral mucosa, especially in clients who are immobile.

A. Localized edema B. An increase in RBCS C. Bradycardia D. An increase in platelets E. An increase in neutrophils

Correct Answer is ["A","E"]

Explanation

A. Localized edema:
Localized edema, especially when accompanied by erythema (redness), warmth, and tenderness, can be indicative of an infection in a client with diabetes mellitus. Infections in diabetic patients, particularly those affecting the feet, can lead to localized inflammation and swelling.

B. An increase in RBCs:
An increase in red blood cells (RBCs), known as erythrocytosis, is not typically associated with an infection. Erythrocytosis may occur in conditions such as polycythemia vera or chronic hypoxemia but is not a typical marker of infection.

C. Bradycardia:
Bradycardia, a heart rate slower than the normal range, is not typically associated with infections. Infections often cause tachycardia (an increased heart rate) as part of the body's systemic inflammatory response.

D. An increase in platelets:
An increase in platelets, known as thrombocytosis, is not typically associated with infections. Thrombocytosis can occur in response to various factors, including inflammation, but it is not a specific marker of infection in diabetic clients with foot pain.

E. An increase in neutrophils:
An increase in neutrophils, known as neutrophilia, is a common response to infection. Neutrophils are a type of white blood cell involved in the body's immune response to bacterial infections. In diabetic clients with foot pain, an elevated neutrophil count may suggest the presence of an infection, as the body mobilizes these cells to combat the invading pathogens.

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A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as Indications that the client has an infection? (Select all that apply)

Correct Answer is ["A","E"]

Explanation

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