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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Rationale
The frequency and amount of urination indicates that the body in able to utilize glucose reducing glucosuria and osmotic diuresis.
The ability to tolerate oral intake also indicates an improvement in the client’s general health
Improvement in perception of pedal pulses indicates an improvement in the hydration status of the client.
A normal pulse rate and blood pressure is an indicator of optimal hydration status- an improvement from the severely dehydrated state.
The blood glucose levels is dropping indicating an improvement in the glycemic control
Correct Answer is A
Explanation
A. Clients with flail chest often experience compromised respiratory function due to the paradoxical movement of the chest wall. Providing humidified oxygen can help improve oxygenation and maintain airway patency, especially if the client is experiencing hypoxia.
B. Administering antibiotic medication is not a primary intervention for a flail chest unless there is evidence of an associated infection, such as pneumonia
C. Fluid restriction is not typically indicated for a client with a flail chest unless there are specific indications, such as heart failure or renal dysfunction.
D. While managing pain is important, flail chest often requires more aggressive pain management strategies, such as opioid analgesics or regional anesthesia, especially if the pain is severe and affects respiratory effort. Acetaminophen alone may not be sufficient for effective pain control in this situation.
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