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) Hydrochlorothiazide: Hydrochlorothiazide is a thiazide diuretic that promotes sodium and water excretion, leading to decreased blood volume and decreased potassium excretion. While it can cause hypokalemia due to increased potassium excretion, it does not typically lead to hyperkalemia.
B) Spironolactone: Spironolactone is a potassium-sparing diuretic that inhibits aldosterone, leading to decreased sodium reabsorption and increased potassium retention. This mechanism of action can predispose clients to hyperkalemia due to potassium retention. Additionally, spironolactone can cause hyponatremia by promoting the excretion of sodium and water. Therefore, clients receiving spironolactone are at risk for both hyperkalemia and hyponatremia.
C) Furosemide: Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the loop of Henle, promoting sodium, chloride, potassium, and water excretion. While it can cause hypokalemia due to increased potassium excretion, it does not typically lead to hyperkalemia.
D) Metolazone: Metolazone is a thiazide-like diuretic that acts similarly to hydrochlorothiazide by promoting sodium and water excretion. Like hydrochlorothiazide, it can cause hypokalemia due to increased potassium excretion but does not typically lead to hyperkalemia.
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.
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.