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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice **d. Providing client information to another nurse at change of shift**.
Choice A rationale:
Sharing the client's prognosis with a family member without the client's consent violates the client's right to confidentiality. The nurse should only disclose information to family members if the client has provided permission or if it is necessary for the client's care.
Choice B rationale:
Discussing the client's status with a member of the spiritual support team may be appropriate if the client has consented to spiritual support and the nurse limits the discussion to information relevant to the spiritual care. However, disclosing the client's diagnosis or other sensitive information without the client's consent would still be a breach of confidentiality.
Choice C rationale:
Collaborating with a nurse from another unit about the client's care is appropriate if it is necessary for the client's treatment and if the discussion is limited to information relevant to the client's care. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.
Choice D rationale:
Providing client information to another nurse at change of shift is necessary for the continuity of the client's care and is considered an appropriate disclosure within the healthcare team. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.
Correct Answer is C
Explanation
The correct answer is Choice C: Take vitamin D supplements.
Choice A rationale:
Reducing intake of calcium-rich foods would not be a suitable recommendation. Calcium is essential for bone health, and a client with minimal sunlight exposure is at risk of vitamin D deficiency, which affects calcium absorption. Therefore, this choice would worsen the client's situation.
Choice B rationale:
Using sunscreen with an SPF of 8 is unlikely to provide adequate protection against the harmful effects of sunlight. Moreover, the client's issue is vitamin D deficiency due to minimal sunlight exposure, and using sunscreen would further hinder vitamin D synthesis.
Choice C rationale:
Taking vitamin D supplements is the most appropriate intervention. Vitamin D is synthesized in the skin upon exposure to sunlight, and since the client has minimal sunlight exposure, supplements are necessary to prevent vitamin D deficiency. This choice addresses the root cause of the issue.
Choice D rationale:
Using a tanning bed is not recommended for increasing vitamin D levels. Tanning beds emit ultraviolet (UV) radiation, which can increase the risk of skin cancer. Moreover, excessive UV exposure is not a safe or controlled method for addressing vitamin D deficiency.
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