A nurse is planning care for a client who is on droplet precautions. Which of the following actions should the nurse take for this client?
Ensure all gloves in the client’s room are nonlatex.
Equip the client’s room with a HEPA filtration system.
Place a box of surgical masks outside the client’s room.
Assign the client to a negative pressure room.
The Correct Answer is C
Choice A reason: Nonlatex gloves are relevant for allergies, not droplet precautions, which require masks. Placing surgical masks is key. Assuming gloves are priority risks neglecting respiratory protection, potentially increasing transmission, critical to avoid in ensuring effective infection control for droplet-borne illnesses in healthcare settings.
Choice B reason: HEPA filtration is for airborne precautions, not droplet, which needs masks. Placing surgical masks is correct. Assuming HEPA is needed risks misapplying resources, potentially diverting focus from droplet transmission prevention, critical to prevent in ensuring proper infection control for clients on droplet precautions.
Choice C reason: Placing surgical masks outside the room is essential for droplet precautions, ensuring staff and visitors wear masks to prevent respiratory transmission. This is critical for infection control, reducing spread, protecting others, and adhering to CDC guidelines for managing droplet-borne infections in healthcare settings.
Choice D reason: Negative pressure rooms are for airborne precautions, not droplet, which requires masks. Assuming negative pressure is needed risks inappropriate room assignment, potentially increasing transmission, critical to avoid in ensuring correct infection control measures for clients on droplet precautions in healthcare facilities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Urine output of 20 mL/hr is below the desired 30 mL/hr during magnesium sulfate therapy, indicating potential toxicity or renal issues, not a therapeutic effect. Absence of eclampsia is the goal. Monitoring for low output risks missing seizure prevention, critical for maternal safety in preeclampsia management.
Choice B reason: Fetal heart rate of 116/min is within normal (110-160/min) but not a direct therapeutic effect of magnesium sulfate, which prevents seizures. Absence of eclampsia is key. Assuming heart rate is the focus risks overlooking maternal neurological status, critical for ensuring seizure prevention in preeclampsia treatment.
Choice C reason: Blood pressure of 150/92 mm Hg, while elevated, is not the primary therapeutic effect of magnesium sulfate, which targets seizure prevention, not hypertension. Absence of eclampsia is priority. Focusing on blood pressure risks neglecting seizure monitoring, critical for maternal safety in preeclampsia management with magnesium.
Choice D reason: Absence of eclampsia (seizures) is the primary therapeutic effect of magnesium sulfate in preeclampsia, stabilizing neuronal excitability, preventing life-threatening convulsions. Monitoring this ensures maternal safety, critical for preventing neurological damage, supporting fetal well-being, and guiding therapy adjustments in high-risk obstetric care.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Potential complications must be explained before consent to ensure the client understands risks like bleeding or infection, supporting informed decision-making. This is legally required, critical for ethical care, preventing misunderstandings, and ensuring the client is fully aware of colon resection’s potential adverse outcomes before signing.
Choice B reason: Possible alternative treatments, like medication or less invasive procedures, must be discussed to ensure informed consent, allowing the client to weigh options. This is essential for autonomy, critical for ethical practice, ensuring clients understand all viable paths before agreeing to a colon resection procedure.
Choice C reason: An explanation of the procedure, including what a colon resection entails, is required for informed consent, ensuring the client understands the surgical process. This promotes transparency, critical for legal and ethical standards, enabling informed decisions and reducing anxiety before signing the consent form.
Choice D reason: Expected outcomes, such as symptom relief or recovery timeline, must be provided to clarify the procedure’s benefits, ensuring informed consent. This is crucial for setting realistic expectations, supporting client autonomy, and ensuring understanding of colon resection’s purpose, critical for ethical surgical consent processes.
Choice E reason: Cost of the procedure is not typically required for informed consent, which focuses on medical risks, benefits, and alternatives. Assuming cost is necessary risks diverting focus from clinical information, potentially overwhelming the client, critical to avoid in ensuring informed consent for colon resection surgery.
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