A nurse is caring for a client who has measles. Which of the following types of precautions should the nurse implement?
Airborne
Droplet
Contact
Protective
The Correct Answer is A
Choice A reason: Airborne precautions are required for measles because the virus is transmitted via small respiratory droplets that can remain suspended in the air for long periods. Clients with measles should be placed in a negative pressure room, and staff should wear N95 respirators to prevent inhalation of airborne particles.
Choice B reason: Droplet precautions are used for larger respiratory droplets, such as those from influenza or pertussis. Measles requires stricter airborne precautions due to its high transmissibility.
Choice C reason: Contact precautions are used for infections spread by direct contact, such as C. difficile or MRSA. Measles is not primarily spread by contact, so this is insufficient.
Choice D reason: Protective precautions are used for immunocompromised clients to protect them from infection, not for clients with measles.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Offering a warm blanket is an act of comfort and beneficence, but it does not demonstrate veracity. Veracity refers to truthfulness and honesty in communication. Providing physical comfort is important, but it does not involve conveying truthful information to the client.
Choice B reason: Reinforcing the provider’s explanation of the potential risks of treatment demonstrates veracity because the nurse is ensuring that the client receives accurate, truthful, and clear information. Veracity requires honesty and transparency in communication, and by reinforcing the provider’s explanation, the nurse helps the client understand the risks and make an informed decision. This is the correct answer.
Choice C reason: Avoiding giving information to family members over the phone demonstrates confidentiality, not veracity. While confidentiality is an ethical principle, it is distinct from veracity, which focuses on truthfulness in communication with the client.
Choice D reason: Asking the client their preferred site for IV insertion demonstrates respect for autonomy and patient-centered care, but it does not involve truth-telling. This action supports client choice but is not an example of veracity.
Correct Answer is A
Explanation
Choice A reason: Reporting suspected abuse to Adult Protective Services is the nurse’s legal and ethical responsibility. Visible contusions on all extremities raise concern for physical abuse, and mandatory reporting laws require healthcare providers to notify protective services to ensure client safety. This is the correct action.
Choice B reason: Interviewing the client with the adult child present is inappropriate because it may prevent the client from speaking honestly about the situation. The presence of a potential abuser can inhibit disclosure and compromise assessment accuracy.
Choice C reason: Telling the client they must answer every Question is coercive and violates patient autonomy. Clients have the right to refuse to answer questions, and forcing responses is non-therapeutic.
Choice D reason: Advising the client to consult a social worker is supportive but insufficient. While social workers provide resources and counseling, the priority action is mandatory reporting to ensure immediate safety.
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