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 {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

The rationale for identifying the client as at risk for hypoxia is based on the respiratory assessment findings. Diminished lung sounds in the posterior lobes suggest reduced air movement or potential complications such as atelectasis or pneumonia, which can impair gas exchange. Additionally, the decreased oxygen saturation of 84% on room air indicates inadequate oxygenation of the blood. Hypoxia occurs when there is insufficient oxygen supply to tissues, which can lead to serious complications if not addressed promptly. Therefore, recognizing these respiratory assessment findings is crucial for identifying the risk of hypoxia in the client.

A. Verify the oxygen flow rate every other day. B. Post NO SMOKING signs in a prominent location in the home. C. Notify local fire department D. Apply petroleum ointment to nares if they become dry and imitated. E. Check the tops of the ears for skin breakdown.

Correct Answer is ["B","C","E"]

Explanation

B. Post NO SMOKING signs in a prominent location in the home:
Oxygen supports combustion, making smoking or exposure to open flames highly dangerous in an oxygen-enriched environment. Posting NO SMOKING signs serves as a reminder to everyone in the household to avoid smoking or using open flames near the oxygen source.

C. Notify local fire department:
It's crucial to inform the local fire department that a client is using home oxygen therapy. This ensures that emergency responders are aware of the presence of oxygen in the home in case of a fire or emergency situation.

E. Check the tops of the ears for skin breakdown:
The nasal cannula can cause pressure on the tops of the ears, potentially leading to skin breakdown, especially with prolonged use. Checking for skin breakdown and providing appropriate skin care helps prevent complications and ensures the client's comfort.

A. Verify the oxygen flow rate every other day:
While it's essential to ensure that the oxygen equipment is functioning properly and that the prescribed flow rate is appropriate for the client's needs, checking it every other day may not be necessary unless there are specific concerns or changes in the client's condition.

D. Apply petroleum ointment to nares if they become dry and irritated:
While it's common for the nasal passages to become dry with oxygen therapy, applying petroleum ointment may not be recommended without consulting the healthcare provider first, as it can interfere with oxygen delivery and increase the risk of infection.

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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?

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Explanation

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