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. Applying a lubricating lotion to cracked areas is appropriate for clients with peripheral arterial disease (PAD). This helps to prevent further skin breakdown and maintain skin integrity, which is crucial since clients with PAD have poor circulation and are at risk for ulcers and infections.

B. Resting with feet elevated is not recommended for clients with PAD. Elevating the feet can further reduce blood flow to the lower extremities. Instead, the client should avoid elevating the legs and should consider positioning the feet at heart level or in a dependent position to promote circulation.

C. Soaking feet in hot water is not recommended for clients with PAD because they may have reduced sensation and are at risk for burns. Additionally, hot water can exacerbate circulation problems and increase the risk of injury.

D. Using a heating pad is not recommended for clients with PAD because they may have impaired sensation in their feet. The heating pad could cause burns or other injuries due to the lack of feeling in the affected areas.

A. "You should avoid intercourse to prevent injury to your vagina." B. "Women your age experience thickening of the vaginal tissue." C. "Your symptoms are likely due to decreasing estrogen levels." D. "These discomforts should decrease with time."

Correct Answer is C

Explanation

A. Avoiding intercourse is not necessary unless there is discomfort, but the focus should be on managing symptoms like vaginal dryness. It is important to address the root cause of the discomfort, which is often related to hormonal changes rather than avoiding sexual activity.

B. Thickening of the vaginal tissue is not typical in older women. In fact, due to decreasing estrogen levels, vaginal tissue often becomes thinner, drier, and less elastic, which can contribute to discomfort and dryness.

C. Decreasing estrogen levels are a common cause of vaginal dryness and itching in older adult women, especially during and after menopause. Estrogen helps maintain the health of vaginal tissues, and a decrease in this hormone leads to symptoms such as dryness, itching, and discomfort.

D. Discomforts decreasing with time is not accurate. While some symptoms may improve with treatment, vaginal dryness and itching are typically chronic issues that require management, such as with estrogen therapy or lubricants, rather than resolving on their own.

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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 providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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