A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take?
Place the client in a semiprivate room.
Have the client apply a mask when children are visiting.
Cleanse hands with an alcohol-based hand rub before client contact.
Use sterile gloves to provide perineal care.
The Correct Answer is C
When caring for an immunocompromised client, the nurse should prioritize infection prevention and control measures. One essential action is to cleanse hands with an alcohol-based hand rub before client contact. Hand hygiene is crucial in reducing the transmission of microorganisms and preventing infections. Using an alcohol-based hand rub is effective in killing many types of germs, including bacteria and viruses.
Let's now discuss why the other
Options are not the correct answers:
a. Place the client in a semiprivate room: Placing the client in a semiprivate room increases the risk of exposure to potential infections from other individuals. Immunocompromised clients have a weakened immune system, making them more susceptible to infections. Therefore, it is recommended to provide them with a private room to minimize the risk of exposure to pathogens.
b. Have the client apply a mask when children are visiting: While it is generally important to take precautions when visitors are present, having the client wear a mask when children are visiting may not be sufficient to protect the immunocompromised client. Children can carry and transmit various infectious diseases, even without displaying symptoms. Therefore, it is more appropriate for healthcare providers and visitors, including children, to adhere to strict hand hygiene and other infection control measures to minimize the risk of infection transmission.
d. Use sterile gloves to provide perineal care: The use of sterile gloves is not necessary for routine perineal care unless there is a specific indication, such as an open wound or surgical site. For routine perineal care, clean, non-sterile gloves are sufficient. Using sterile gloves unnecessarily can contribute to the development of antimicrobial resistance and increase healthcare costs without providing any additional benefits.
In summary, when caring for an immunocompromised client, the nurse should prioritize infection prevention and control. Cleansing hands with an alcohol-based hand rub before client contact is an important action to reduce the risk of infection transmission. The other
Options, such as placing the client in a semiprivate room, having the client wear a mask when children are visiting, and using sterile gloves for routine perineal care, are not the appropriate actions in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
As individuals age, it is common for them to experience a decreased sense of balance. This can be attributed to age-related changes in the musculoskeletal system, sensory perception, and coordination. The inner ear, which plays a vital role in maintaining balance, undergoes natural degenerative changes over time. Additionally, age-related decline in muscle strength and flexibility can contribute to difficulties in maintaining balance. Therefore, a nurse assessing an older adult client should expect a decreased sense of balance as a common finding.
- Nighttime urinary incontinence: While nighttime urinary incontinence can occur in some older adults, it is not a universal finding. It is important to avoid making assumptions or generalizations about older adults experiencing urinary incontinence. Each individual's urinary function can vary, and incontinence can be influenced by various factors such as overall health, bladder capacity, medication use, and underlying medical conditions.
- Heightened sense of pain: Older adults may experience changes in pain perception due to age-related physiological changes and medical conditions. However, it is not a predictable or expected finding for all older adult clients. Pain perception can vary among individuals based on their overall health, chronic conditions, and individual pain thresholds. Therefore, while some older adults may experience heightened pain sensitivity, it is not a universal expectation.
- Increased nighttime sleeping: Sleep patterns can change with age, and older adults may experience alterations in their sleep-wake cycles. However, increased nighttime sleeping is not a definitive finding that applies to all older adult clients. Sleep patterns can vary greatly among individuals, and some older adults may experience decreased sleep duration or disrupted sleep rather than increased nighttime sleeping.
In summary, the nurse should expect a decreased sense of balance as a common finding when assessing an older adult client. It is important to approach each individual as unique and recognize that other findings such as nighttime urinary incontinence, heightened sense of pain, or increased nighttime sleeping may or may not be present, as they can vary among older adults based on individual factors.
Correct Answer is B
Explanation
The correct answer is that the nurse should recommend the client to eat a light carbohydrate snack before bedtime. Eating a light carbohydrate snack before bedtime can help promote sleep by increasing the level of tryptophan in the brain, which can help induce sleep.
Options a, c and d are not appropriate interventions for insomnia. Taking a 30-min nap daily can disrupt nighttime sleep and worsen insomnia. Exercising 1 hr before bedtime can increase alertness and make it harder to fall asleep. Drinking a cup of hot cocoa before bedtime can also disrupt sleep due to its caffeine content.
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