A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

A client who has pneumonia.

A client who has measles.

A client who has pertussis.

A client who has methicillin-resistant Staphylococcus aureus (MRSA).

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: A client who has measles.

Choice A rationale:

Airborne precautions are indicated for diseases that spread via small particles suspended in the air, such as droplets or dust particles that remain in the air for prolonged periods. Pneumonia is primarily spread through larger respiratory droplets and is not considered an airborne disease. Therefore, airborne precautions are not necessary for a client with pneumonia.

Choice B rationale:

Measles is a highly contagious airborne disease caused by the measles virus. It is transmitted through respiratory droplets and can remain in the air for an extended period. Initiating airborne precautions, such as wearing an N95 respirator mask and placing the client in a negative pressure isolation room, is crucial to prevent the spread of measles to healthcare workers and other patients.

Choice C rationale:

Pertussis (whooping cough) is primarily spread through respiratory droplets, similar to pneumonia. While it is a serious bacterial infection, it is not classified as an airborne disease. Thus, airborne precautions are not required for a client with pertussis.

Choice D rationale:

Methicillin-resistant Staphylococcus aureus (MRSA) is mainly spread through direct contact with contaminated surfaces or individuals. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air. Standard precautions, including wearing gloves and gowns, are typically sufficient when caring for a client with MRSA.

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Correct Answer is B

Explanation

The correct answer is choice B: Empty the drainage bag when it is three-fourths full.

Choice A rationale:

Cleaning the perineal area at least once a day is important for maintaining hygiene, but it is not the most relevant action in this scenario. The focus here is on managing the urinary catheter and its drainage bag.

Choice B rationale:

Emptying the drainage bag when it is three-fourths full is the correct action. An indwelling urinary catheter requires regular drainage to prevent the risk of infection and blockages. Allowing the bag to become too full could lead to backflow and increase the likelihood of urinary tract infections.

Choice C rationale:

Flushing the catheter with sterile water daily is not typically part of routine catheter care. Catheter flushing might be done for specific medical reasons, but it is not a general guideline for indwelling catheters.

Choice D rationale:

Disconnecting the drainage bag when emptying and measuring urine is incorrect. Maintaining a closed system is crucial to prevent introducing bacteria into the urinary tract. Disconnecting the bag could increase the risk of infection.

A. "You will need to look to the side when you put the drops in your eye." B. "You should put the drops directly in the center of your eyeball." C. "You should cleanse your eye from the inner to the outer edge prior to putting in the drops." D. "You should avoid pressing on your tear duct after putting the drops in your eye.”

Correct Answer is C

Explanation

The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”

Choice A rationale:

Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.

Choice B rationale:

Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.

Choice C rationale:

Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.

Choice D rationale:

Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.

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A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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