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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hyponatremia: Hyponatremia is characterized by low sodium levels in the blood and can lead to symptoms such as weakness, confusion, and seizures. While hyponatremia can contribute to fluid imbalance, the client's presentation with shortness of breath, lower extremity swelling, crackles in the lungs, and elevated blood pressure is more indicative of fluid volume excess rather than hyponatremia.
B. Hypervolemia: Hypervolemia, or fluid volume excess, occurs when there is an abnormal increase in the extracellular fluid volume. This can lead to symptoms such as shortness of breath, crackles in the lungs (indicative of pulmonary edema), peripheral edema, and elevated blood pressure. Given the client's reported symptoms and assessment findings, hypervolemia is the most likely diagnosis.
C. Hypovolemia: Hypovolemia, or fluid volume deficit, occurs when there is a decrease in the extracellular fluid volume. This condition is characterized by symptoms such as thirst, dry mucous membranes, decreased urine output, and hypotension. The client in this scenario presents with signs and symptoms consistent with fluid volume excess rather than hypovolemia.
D. Hyperkalemia: Hyperkalemia is characterized by elevated potassium levels in the blood and can lead to symptoms such as muscle weakness, cardiac dysrhythmias, and nausea. While hyperkalemia can occur in clients with end-stage kidney disease, the client's reported symptoms and assessment findings are more suggestive of fluid volume excess rather than hyperkalemia.
Correct Answer is D
Explanation
A. Chocolate milk:
Chocolate contains caffeine, which can contribute to sleep disturbances. It is not a recommended beverage for someone looking to decrease caffeine intake.
B. Diet cola:
Cola contains caffeine, even in diet versions, which can contribute to sleep disturbances. Therefore, it is not suitable for decreasing caffeine intake.
C. Brewed iced tea:
Brewed iced tea contains caffeine, which can interfere with sleep. It is not a suitable option for someone trying to reduce caffeine consumption.
D. Lemon-lime soda:
Lemon-lime sodas typically do not contain caffeine, making them a better choice for someone looking to reduce their caffeine intake and improve sleep.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
