A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?

Droplet precautions

Airborne precautions

Protective environment

Contact precautions

Answer and Explanation

The Correct Answer is D

Herpes simplex is primarily transmitted through direct contact with the skin or mucous membranes of an infected individual. Contact precautions are designed to prevent the spread of microorganisms that are transmitted by direct contact or indirect contact with contaminated surfaces. These precautions include wearing gloves and a gown when entering the client's room, ensuring proper hand hygiene, and using dedicated equipment for the client.

Droplet precautions are used for infections that are transmitted through respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis.

Airborne precautions are used for infections that are transmitted by smaller droplet nuclei that can remain suspended in the air for longer periods, such as tuberculosis or measles.

Protective environment is a specialized isolation precaution used for clients with compromised immune systems, such as those undergoing stem cell transplantation, and involves strict control of the environment to reduce the risk of acquiring infections.

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Correct Answer is C

Explanation

Assessing the client's ability to use the call light is crucial for their safety and well-being. If the client is unable to use the call light to request assistance, it increases the risk of falls or accidents when they attempt to move or perform tasks without assistance. By determining the client's ability to use the call light, the nurse can ensure that appropriate measures are in place to enable the client to call for help whenever needed.

Applying rubber-soled slippers before ambulation helps to provide better traction and reduce the risk of slips and falls, but it can be implemented after assessing the client's ability to use the call light.

Moving the bedside table closer to the bed is helpful for the client to access personal items without the need to reach or stretch, but it is not the highest priority among the given options.

Creating a schedule with assistive personnel for hourly rounding is important for regular checks on the client's safety and well-being, but it can be arranged after assessing the client's ability to use the call light.

A. Ecchymosis on the inner left thigh B. One fingerbreadth of space between the cast and the skin C. Diminished pulses on the aﬀected extremity D. Client report of muscle spasms of the left leg

Correct Answer is C

Explanation

c. Diminished pulses on the aﬀected extremity. This finding may indicate compromised circulation, which is

a serious complication that requires immediate intervention.

Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.

Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.

Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may

be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the aﬀected extremity.

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A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

Correct Answer is C

Explanation

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