A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention nurse's supervisor?
The nurse wears gloves when providing direct care to the patient.
The nurse admits another client who has shingles to the client’s double room.
The nurse wears a gown when bathing the client.
The nurse wears an N95 respirator mask
The Correct Answer is B
Choice A rationale: Wearing gloves is appropriate when providing direct care to a client with shingles to prevent the spread of the virus.
Choice B rationale: Shingles is caused by the varicella-zoster virus, and it is highly contagious. Placing a client with shingles in a double room increases the risk of spreading the virus to other clients, especially those with compromised immune systems.
Choice C rationale: Wearing a gown is appropriate when there is a risk of contact with the client's lesions to prevent the spread of the virus.
Choice D rationale: While wearing a mask may be indicated for certain respiratory conditions, it is not typically required when caring for a client with shingles.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Swabbing the wound bed is necessary to obtain the culture specimen, but it must not be done until after the wound and surrounding area have been cleansed. Swabbing an uncleaned wound will collect superficial skin flora and debris rather than the true pathogens causing the infection.
B. According to evidence-based practice and nursing guidelines for wound care, the nurse must first cleanse the wound and surrounding area with sterile saline (or an approved non-antiseptic cleanser) to remove exudate, topical medications, and normal skin flora. This ensures that the culture specimen reflects the actual microorganisms responsible for the internal wound infection, making it the highest priority first step.
C. Donning sterile gloves is an appropriate action to maintain surgical asepsis during a sterile dressing change or wound culture procedure, but it is not the first action. The nurse typically wears clean gloves to remove the old dressing and cleanse the wound before transitioning to sterile gloves, or performs hand hygiene before preparing the sterile culture kit.
D. Placing the collection tube into a biohazard specimen bag is a necessary final step performed after the specimen has been successfully collected, labeled, and sealed to ensure safe transport to the laboratory, so it cannot be the first action taken.
Correct Answer is B
Explanation
Choice A rationale: While impaired tissue perfusion can affect activity tolerance, addressing the underlying perfusion issue takes precedence.
Choice B rationale: Varicose veins with ulcerations and lower extremity edema suggest impaired tissue perfusion. The compromised blood flow can lead to poor oxygenation and nutrient delivery to tissues, increasing the risk of ulceration and delayed wound healing.
Choice C rationale: Impaired tissue perfusion contributes to impaired skin integrity, but it is not the primary issue.
Choice D rationale: While varicose veins can impact body image, addressing impaired tissue perfusion is more critical for the client's overall well-being.
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