A nurse is caring for several hospitalized clients.
Contact precautions would be mandated for the client with which diagnosis?
Hepatitis B.
Measles.
Meningitis.
Infectious diarrhea.
The Correct Answer is D
Choice D rationale:
When preparing to open a sterile pack, the nurse must touch only the inner surface of the inner wrapper to maintain sterility. This is a fundamental principle of aseptic technique. Sterile items should be handled with care to prevent contamination. By touching only the inner surface of the inner wrapper, the nurse ensures that the contents of the pack remain sterile and safe for use in medical procedures. Any contact with the outer surface or other non-sterile items can compromise the sterility of the contents.
Choice A rationale:
Placing the sterile pack on a clean surface is a good practice but does not ensure the maintenance of sterility. Sterile items should be placed on a sterile surface or field to prevent contamination. Placing the pack on a clean surface may still expose it to potential contaminants, compromising its sterility.
Choice B rationale:
Turning the pack so that the first flap faces the nurse's body is incorrect. The first flap should be opened away from the nurse to avoid the risk of contamination. By opening the flap away from the nurse, any potential contaminants in the air are less likely to come into contact with the sterile contents.
Choice C rationale:
Opening the right-side flap first is not a standard practice for opening a sterile pack. The choice of which side to open first may vary based on individual preference or the design of the packaging. The key factor is to maintain the sterility of the contents by handling the pack appropriately, as mentioned in choice D.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Standard precautions, as established by the Center for Disease Control (CDC), are to be used for any client, regardless of whether an infection has been identified. This means that healthcare providers, including nurses, must apply standard precautions in the care of all patients to prevent the spread of infections. The rationale behind this choice is based on the fundamental principle of infection control: it is not always possible to identify patients who may be carrying harmful pathogens. Some patients may not show visible signs of infection or may be in the incubation period of a disease, during which they are contagious but not symptomatic. Therefore, applying standard precautions universally helps to create a safe healthcare environment for both patients and healthcare providers. Standard precautions include practices such as hand hygiene, the use of personal protective equipment (PPE) like gloves and masks, safe injection practices, and respiratory hygiene.
Choice B rationale:
This choice incorrectly specifies the mode of transmission for using standard precautions. Standard precautions are not limited to cases where the infection is transmitted on air currents. Airborne precautions are used for diseases that spread via small droplets in the air, such as tuberculosis and measles. Standard precautions, on the other hand, cover a broader range of infections and are applied to all patients.
Choice C rationale:
This choice incorrectly narrows down the usage of standard precautions to cases where the infection spreads via moist droplets. While it is true that standard precautions include measures to prevent the transmission of infections through respiratory droplets, they are not limited to this mode of transmission. Standard precautions encompass various modes of transmission, including contact with blood and other body fluids, as well as contact with contaminated surfaces or items.
Choice D rationale:
This choice wrongly states that standard precautions are only used when there is an infection spread by indirect contact with an organism. Standard precautions include both direct and indirect contact with patients and their environment. It is not limited to specific types of infections or modes of transmission.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Keeping the walker at the end of the bed is inconvenient and increases the risk of falls. The walker should be easily accessible, ideally placed near where the client gets up from bed, to provide immediate support.
Choice B rationale: Fluorescent ceiling lights can be too harsh and cause glare, making it difficult for the client to see properly at night. Instead, using a nightlight or a softer, dimmable light source is recommended to provide safe, clear visibility.
Choice C rationale: Placing an area rug at the entry of the bathroom poses a tripping hazard. Loose rugs can easily shift and cause falls. It's better to use non-slip mats or secure carpeting to ensure safe footing, especially in areas prone to moisture.
Choice D rationale: Using a bath seat in the shower reduces the risk of slipping and falling. It provides a stable and secure place to sit while bathing, which is particularly important for clients with a history of falls or limited mobility.
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