A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Monitor the client's temperature once every 6 hr.

Wear an N95 respirator when providing direct client care.

Make sure dietary plates and utensils are disposable.

Make sure the client's room has positive-pressure airflow.

Answer and Explanation

The Correct Answer is D

A. Clients in protective isolation require more frequent temperature monitoring due to their high risk for infection. Monitoring once every 6 hours may not be sufficient to detect early signs of infection.
B. An N95 respirator is necessary for airborne precautions (e.g., tuberculosis) but is not required for protective isolation unless indicated for another reason.
C. While disposable plates and utensils may be used, they are not a primary requirement for infection prevention in protective isolation. Properly cleaned and sanitized utensils are generally safe.
D. Protective isolation requires positive-pressure airflow to prevent airborne pathogens from entering the client’s room, reducing the risk of infection in immunocompromised individuals.

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Correct Answer is A

Explanation

A. Humidified oxygen is an essential intervention for a client with flail chest. Flail chest occurs when multiple rib fractures result in a segment of the chest wall that moves independently during breathing. This leads to respiratory distress, and providing humidified oxygen helps improve oxygenation and reduce airway irritation.

B. Fluid restriction is not indicated for flail chest unless there is another specific condition (e.g., heart failure) that requires it. The primary concern in flail chest is respiratory support, not fluid management.

C. While acetaminophen may be used for pain management, it is not the priority in managing flail chest. Pain control is important, but the focus should be on ensuring adequate ventilation and oxygenation.

D. Antibiotic medication is not indicated unless there is evidence of infection, such as pneumonia. Flail chest itself does not require antibiotics unless there are associated complications like a chest infection.

A. Exhale slowly through pursed lips. B. Position the mouthpiece 2.5 cm (1 in) from the mouth. C. Hold breaths about 3 to 5 seconds before exhaling. D. Place hands on the upper abdomen during inhalation.

Correct Answer is C

Explanation

A. Exhaling slowly through pursed lips is a technique often used in conditions like chronic obstructive pulmonary disease (COPD) to prevent air trapping, but it is not a required step when using an incentive spirometer. The primary focus should be on deep inhalation to expand the lungs fully.

B. Positioning the mouthpiece 2.5 cm (1 in) from the mouth is incorrect. The mouthpiece should be placed securely in the mouth, ensuring a tight seal to create the necessary pressure for the spirometer to function properly.

C. Holding the breath for 3 to 5 seconds before exhaling is the correct instruction. This pause helps to allow the lungs to expand fully and ensures maximum inhalation, which is the goal of using the incentive spirometer.

D. Placing hands on the upper abdomen during inhalation is not necessary for using an incentive spirometer. The focus should be on deep, slow inhalations, and while some people may naturally place hands on their abdomen to help monitor their breathing, it is not a required step in the process.

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A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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