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.
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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Related Questions
Correct Answer is D
Explanation
A. Monitoring urine for white blood cells is not directly related to the use of ibuprofen. White blood cells in the urine are more indicative of an infection, such as a urinary tract infection.
B. Fasting blood glucose is not typically required for monitoring the effects of ibuprofen. Although ibuprofen can affect renal function, it does not directly impact blood glucose levels.
C. Serum calcium is not the most relevant test for monitoring the effects of long-term ibuprofen use. Ibuprofen can affect kidney function, but calcium levels are not the primary concern.
D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation and increase the risk of gastrointestinal bleeding. Monitoring stool for occult blood is important to detect any potential bleeding from the gastrointestinal tract, which is a common side effect of chronic NSAID use.
Correct Answer is A
Explanation
A. Supporting the feet with a rolled pillow when the client is lying on their back is a correct positioning strategy. It helps maintain proper alignment and prevents foot drop, which is a common concern in clients with hemiplegia.
B. Using a thick pillow under the head can cause excessive neck flexion, which can lead to discomfort and poor alignment. A thinner pillow is typically recommended to maintain neutral head and neck positioning.
C. Ensuring the neck is flexed backward when the client is lying on their stomach is incorrect. The neck should remain in a neutral position to avoid strain or injury.
D. Resting the heels on the mattress when the client is sitting up in bed is not recommended, as it can increase the risk of pressure ulcers. It is better to use heel protectors or pillows to elevate the heels off the mattress and prevent pressure.
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