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.

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

Wear an N95 respirator when providing direct client care.

Make sure dietary plates and utensils are disposable.

Answer and Explanation

The Correct Answer is C

A. Monitoring of vital signs should be more frequent

B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.

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Correct Answer is A

Explanation

A. Frequent vitals monitoring to allow for early detection of infection. Clients with neutropenia are at increased risk of infections.
B. Indwelling catheter and other devices should be avoided in individuals with neutropenia die to risk of sepsis.
C. Changing the client’s linen is important. However, doing it 3 times a day is not necessary.
D. Clients should be placed in a positive airflow room to prevent contracting infections from infected persons

A. Gentle bubbling in the water seal chamber B. Drainage and warmth at tube insertion site C. Crackling sensation felt around tube insertion site D. Drainage output less than 70 mL/hr

Correct Answer is A

Explanation

A. Bubbling indicates that the system is functioning properly and that air is being evacuated from the pleural space.
B. Drainage and warmth at the tube insertion site could indicate inflammation or infection, which are potential complications following insertion of a chest tube.
C. Crackling sensation felt around tube insertion site could indicate subcutaneous emphysema, which occurs when air leaks into the tissues surrounding the chest tube insertion site. It's a potential complication of chest tube insertion and should be monitored closely

D. The specific amount can vary.

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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 admitting a client who has neutropenia. Which of the following precautions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate?

Correct Answer is A

Explanation

A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

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A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?

A charge nurse is observing a newly licensed nurse care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA). Which of the following observations of the newly licensed nurse indicates an understanding of infection control precautions?