A nurse is planning care for a client who has contact precautions in place. Which of the following actions should the nurse plan to take when removing soiled linens from the client's room?
Double-bag the linens.
Rinse the linens prior to removing them from the client's room.
Tie the linens' bag securely at the top.
Wear sterile gloves when handling the linens.
The Correct Answer is C
A. Double-bag the linens: Double-bagging is no longer a standard requirement unless the outside of the primary bag is visibly soiled or the bag is punctured. Modern infection control guidelines focus on the integrity of a single, sturdy, leak-proof bag to reduce waste and cost.
B. Rinse the linens prior to removing them from the client's room: Rinsing the linens is not required when removing soiled linens. The main concern is preventing contamination, and double-bagging ensures that the linens are safely contained.
C. Tie the linens' bag securely at the top: The primary goal of isolation protocol is to contain the pathogen within the designated "dirty" area. By tying the bag securely, the nurse ensures that no contaminated fluid or air is released as the bag is moved through the hallways of the facility. Standard practice requires placing linens in a leak-proof laundry bag labeled for biohazardous or contaminated materials.
D. Wear sterile gloves when handling the linens: Sterile gloves are not necessary for handling soiled linens in contact precautions. Clean gloves are sufficient to handle linens. Sterile gloves are typically used for invasive procedures, not for routine linen handling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Place the client in a supine position: The position should prioritize the client’s safety and comfort, considering their condition and the risk of aspiration or discomfort. A supine position may not be the most appropriate for this client’s agitation or confusion.
B. Attach the straps to the side rails of the bed frame: Attaching the restraints to the side rails could be dangerous, as it may cause injury or further agitation. Restraints should be attached to a non-movable part of the bed to ensure the client’s safety and prevent injury due to entrapment.
C. Secure the straps with a square knot: Restraints should not be secured with a square knot, as this could make them difficult to release quickly in an emergency. Instead, the restraint should be fastened in a way that allows for quick removal when needed to ensure the client's safety.
D. Remove the restraints every 2 hr: It is essential to remove restraints at least every 2 hours to check for any signs of injury, provide comfort, and ensure circulation. Removing restraints allows for proper skin care and reduces the risk of complications like pressure ulcers.
Correct Answer is D
Explanation
A. Oral temperature 37.4°C (99.3°F): This is a low-grade fever and is generally not concerning unless it increases or persists. It could be related to the body’s response to surgery but does not require immediate reporting to the provider.
B. BP 130/84 mm Hg: This is a normal blood pressure for most adults and does not indicate an issue. There is no immediate concern for the nurse to report this to the provider.
C. Heart rate 88/min: A heart rate of 88 beats per minute is within normal range for an adult and does not require reporting to the provider.
D. Respiratory rate 10/min: A respiratory rate of 10/min is significantly below the normal range for an adult (12-20 breaths per minute) and could indicate respiratory depression, a common side effect of opioid analgesics. This is a serious finding and should be reported to the provider immediately for further evaluation and intervention.
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