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. Clamping the chest tubes is contraindicated because it can lead to tension pneumothorax, a life- threatening condition where air accumulates in the pleural space under pressure. If the chest tube becomes disconnected, the nurse should immediately place the end of the tube in sterile water to maintain the water seal and prevent air from entering the pleural space.
B. The drainage container must always be kept below the level of the client's chest. This position allows gravity to facilitate drainage from the pleural space into the collection chamber. If the container is positioned above the client's chest, drainage could potentially flow back into the pleural space, leading to complications.
C. It is essential to monitor and record the amount and characteristics of drainage regularly. Emptying the collection container at least once every shift ensures accurate measurement of drainage output and helps in assessing the client's response to treatment.
D. The water-seal chamber of the chest drainage system maintains the desired amount of suction (usually
-20 cm H2O) to facilitate lung re-expansion. This chamber should be filled with sterile water to the recommended level, usually marked on the device. Adding tap water can introduce contaminants and should be avoided.

A. Temperature 38.2° C (100.8° F) B. Hematocrit 45% C. Respiratory rate 12/min D. Urine specific gravity 1.015

Correct Answer is A

Explanation

A. This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B. Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues

or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C. A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D. Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.

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

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is A

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