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. Mannitol is the medication of choice for managing increased intracranial pressure (ICP). It is an osmotic diuretic that reduces ICP by drawing fluid out of the brain and into the bloodstream, which is then excreted by the kidneys. This helps to decrease cerebral edema and improve cerebral perfusion.

B. Chlorpromazine is an antipsychotic medication and is not used to treat increased ICP. It may be used for other conditions, such as agitation or nausea, but not for ICP management.

C. Dobutamine is a positive inotropic medication used to increase cardiac output in conditions such as heart failure, but it is not indicated for increased ICP.

D. Propranolol is a beta-blocker used to manage hypertension or anxiety, but it does not directly address the underlying issues of increased ICP.

A. Decreased coagulation B. Decreased serum lipid levels C. Proteinuria D. Hyperalbuminemia

Correct Answer is C

Explanation

A. Decreased coagulation is not a characteristic finding in nephrotic syndrome. In fact, nephrotic syndrome can increase the risk of thromboembolic events due to the loss of anticoagulants in the urine.

B. Decreased serum lipid levels are not expected in nephrotic syndrome. In fact, nephrotic syndrome is often associated with increased serum lipid levels (hyperlipidemia), as the liver increases production of lipoproteins in response to protein loss.

C. Proteinuria is a hallmark of nephrotic syndrome. The condition is characterized by excessive protein loss in the urine, which leads to hypoalbuminemia and edema.

D. Hyperalbuminemia is not expected in nephrotic syndrome. The condition typically leads to hypoalbuminemia due to the loss of albumin in the urine.

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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?

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Naxlex Comprehensive Predictor Exams

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