A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?

Wear a mask when entering the client's room.

Dedicate equipment and supplies for use with the client.

Allow the client to leave the room every 2 hr.

Remove potted plants from the room.

Answer and Explanation

The Correct Answer is B

A.   Contact precautions primarily focus on preventing direct transmission of pathogens through physical contact. Therefore, wearing a mask is not typically required unless the client is also suspected or known to have respiratory infections that require airborne precautions. The standard precautions include wearing gloves and a gown when entering the client's room.
B.   This is a key principle of contact precautions. The nurse should ensure that equipment (such as blood pressure cuffs, stethoscopes) and supplies (like thermometers) used for the client are dedicated solely to that client and are not shared with other clients. This helps prevent the spread of pathogens to other clients or areas of the healthcare facility.
C.   Contact precautions involve limiting the client's movement outside of their room to essential purposes only. Allowing the client to leave the room frequently increases the risk of spreading infectious agents to other areas of the healthcare facility and to other individuals.
D.   Potted plants can harbor soil that may contain microorganisms. Contact precautions focus on preventing direct transmission through physical contact, and while soil is not typically a medium for transmission of common healthcare-associated pathogens, removing plants helps maintain cleanliness and reduces potential reservoirs for contamination.

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Correct Answer is B

Explanation

A. Nocturnal enuresis refers to nighttime bedwetting. In clients with paraplegia and neurogenic bladder, nocturnal enuresis can occur due to impaired bladder sensation or control. However, it does not necessarily indicate the immediate need for catheterization unless accompanied by significant bladder distension or discomfort.
B. Suprapubic discomfort or pain suggests bladder distension, which can occur when the bladder fills beyond its capacity. In clients with neurogenic bladder, this discomfort can be an indication that the bladder needs to be emptied to prevent overdistension and potential complications such as urinary retention or bladder rupture. Therefore, suprapubic discomfort may indicate the need for catheterization.
C. Urge incontinence refers to the sudden and uncontrollable urge to urinate, which leads to involuntary leakage of urine. In clients with neurogenic bladder, urge incontinence can occur due to involuntary bladder contractions. While it indicates an inability to control bladder function, it may not always necessitate immediate catheterization unless it persists or is accompanied by other symptoms.
D. Reflex incontinence occurs when the bladder empties without the person's control due to a spinal cord injury or neurological condition. In clients with paraplegia, reflex incontinence is often managed through intermittent catheterization programs. If reflex incontinence episodes are frequent or result in inadequate bladder emptying, it may indicate the need for more frequent catheterization.

A. Muscle hypotonicity B. Positive Chvostek's sign C. Diarrhea D. Tachycardia

Correct Answer is D

Explanation

A. Hypercalcemia can lead to muscle weakness and fatigue rather than hypotonicity. High calcium levels affect neuromuscular function, potentially causing muscle weakness and decreased muscle tone rather than increased flaccidity.
B. Chvostek's sign is a clinical sign of hypocalcemia, not hypercalcemia. It is characterized by facial muscle twitching in response to tapping the facial nerve just anterior to the ear. Therefore, a positive Chvostek's sign would not be expected in hypercalcemia.
C. Hypercalcemia can cause gastrointestinal disturbances such as constipation rather than diarrhea. High calcium levels can lead to decreased smooth muscle contractility in the intestines, resulting in constipation rather than increased motility leading to diarrhea.
D. Hypercalcemia can lead to a variety of cardiovascular effects, including arrhythmias. Tachycardia can occur as a result of increased sensitivity of the heart to catecholamines and altered electrical conductivity in hypercalcemia.

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A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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