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 B

Explanation

Indicates an increased risk of skin breakdown. This is because significant weight loss can lead to muscle wasting and reduced subcutaneous tissue, making the skin more vulnerable.

Bronchodilators, hemoglobin level and oxygen device do not relate directly to skin breakdown

A. Suction the client's airway. B. Empty water from the client's ventilator tubing. C. Increase the client's ventilator flow rate. D. Evaluate the client for a cuff leak.

Correct Answer is D

Explanation

D. Evaluate the client for a cuff leak is the most appropriate action in response to a low-pressure alarm on the ventilator. A cuff leak can cause a drop in ventilator pressure, triggering the alarm. Assessing the client's cuff for leaks and addressing any identified issues can help resolve the alarm and ensure adequate ventilation.
A. Suctioning the client's airway is not the appropriate action in response to a low-pressure alarm on the ventilator.
B. Emptying water from the client's ventilator tubing could be a valid action to take if there is excess condensation or water buildup in the ventilator tubing causing the low-pressure alarm. However, it's not the first action to consider, as other causes should be ruled out first.
C. Increasing the ventilator flow rate may help maintain adequate pressure in the ventilator circuit and address the low-pressure alarm if the cause is related to insufficient airflow. However, adjusting the flow rate should be done cautiously and based on the client's respiratory status and ventilator settings.

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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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Correct Answer is D

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