A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?
Stand 1.8 m (6 feet) away from the client.
Allow the client to ambulate in the hall.
Provide a positive-pressure airflow room.
Wear an N95 respirator mask.
The Correct Answer is D
A. Standing 1.8 m (6 feet) away from the client is not sufficient for airborne precautions.
Proper respiratory protection is required, such as an N95 mask.
B. Allowing the client to ambulate in the hall is not a specific action related to airborne precautions. If the client needs to leave their room, they should wear a mask to prevent the spread of airborne particles.
C. A positive-pressure airflow room is not typically required for airborne precautions.
However, ensuring proper ventilation in the room is important.
D. Airborne precautions are required for clients with illnesses that spread via small droplets or dust particles that can remain in the air for extended periods. This includes diseases like tuberculosis, chickenpox, and measles. The nurse should wear an N95 respirator mask to provide protection against inhaling these particles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B. Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C. Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D. After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.
Correct Answer is B
Explanation
A. A sheepskin heel pad is primarily used for pressure ulcer prevention, not for preventing plantar flexion contractures.
B. A footboard helps maintain the feet in a dorsiflexed position, preventing plantar flexion contractures in clients with impaired mobility. This device provides support and alignment to the lower extremities.
C. A trochanter roll is used to prevent external rotation of the hips and to maintain proper alignment. It is not specifically designed to prevent plantar flexion contractures.
D. An abduction pillow is used to maintain hip alignment and prevent hip adduction. It is not designed to address plantar flexion contractures.
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