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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Diluting each medication with tap water is not a recommended practice. It's important to administer medications in their prescribed form to ensure the client receives the correct dose.
B. Pinching the tube prior to attaching the medication syringe helps prevent the medication from being immediately pulled into the suction equipment. This allows the medication to stay in the stomach for absorption.
C. Reattaching the suction directly after administering the medication would
immediately start suctioning again, which could pull the medication out of the stomach before it has a chance to be absorbed.
D. Mixing the three medications together is not recommended, as some medications may interact with each other, potentially leading to undesirable effects. Each medication should be administered separately to ensure proper absorption and effectiveness.

A. Instruct the client to tighten muscle groups for a short period, then relax. B. Move the client's limbs through their complete range of motion. C. Ask the client to move her arms and legs while applying slight resistance. D. Have the client move each limb independently through its complete range of motion.

Correct Answer is A

Explanation

A. Isometric exercises involve contracting or tensing muscles without actually moving the joint. Instructing the client to tighten muscle groups for a short period and then relax is the correct approach for isometric exercises. This action helps activate and strengthen specific muscle groups without moving the joints.
B. Moving the client's limbs through their complete range of motion is known as passive range of motion exercises. These exercises are important for maintaining joint flexibility but are not isometric.
C. Asking the client to move her arms and legs while applying slight resistance is known as resisted range of motion exercises. These exercises involve active movement against resistance and are not considered isometric.
D. Having the client move each limb independently through its complete range of motion is known as active range of motion exercises. These exercises involve voluntary
movement of each joint through its full range of motion and is not isometric.

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