A nurse is planning care for a patient who has been admitted due to severe coughing, night sweats, and blood in the sputum.
What precautions should the nurse take?
Wear a surgical mask when entering the patient’s room.
Place the patient in a negative-pressure airflow room.
Keep a container for soiled linens outside the patient’s door.
Remain within 3 feet of the patient.
The Correct Answer is B
Choice A rationale
Wearing a surgical mask when entering the patient’s room is a standard precaution for all healthcare workers, but it may not be sufficient for a patient with severe coughing, night sweats, and blood in the sputum. These symptoms could indicate a contagious disease such as tuberculosis, which requires airborne precautions.
Choice B rationale
Placing the patient in a negative-pressure airflow room is the correct action. This type of room is used for patients who may have airborne infectious diseases. The negative pressure prevents airborne pathogens from escaping the room and infecting others.
Choice C rationale
Keeping a container for soiled linens outside the patient’s door is not the most appropriate action in this situation. While it is important to handle soiled linens properly to prevent the spread of infection, it does not address the potential airborne transmission of pathogens.
Choice D rationale
Remaining within 3 feet of the patient is not the most appropriate action in this situation. If the patient has an airborne infectious disease, healthcare workers should minimize close contact to prevent exposure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Without specific patient data, it’s challenging to provide a detailed rationale.
However, initiating seizure precautions could be necessary if the patient’s medical record indicates a history of seizures or a condition that increases the risk of seizures.
Choice B rationale
Assisting the patient to the bathroom is a routine nursing intervention and would not typically be determined based on a review of the patient’s medical record.
Choice C rationale
Keeping the patient’s head in a mid position would depend on the patient’s condition and would not typically be determined based on a review of the patient’s medical record.
Choice D rationale
Decreasing oxygen to 1.5 L/min via nasal cannula would depend on the patient’s oxygen saturation levels and overall respiratory status.
Correct Answer is C
Explanation
Choice C.
Choice A rationale
Keeping both arms below the heart level can actually increase the risk of lymphedema development. This position can lead to pooling of lymphatic fluid in the arm, which can exacerbate swelling.
Choice B rationale
Avoiding range-of-motion exercises with the affected arm is not recommended. Regular gentle exercises can help promote lymphatic drainage and prevent lymphedema.
Choice C rationale
Using the client’s left arm (the non-operated arm) to draw blood samples is a recommended practice. This reduces the risk of infection and injury to the right arm, which could potentially trigger or worsen lymphedema.
Choice D rationale
Obtaining blood pressure readings using the client’s right arm (the operated arm) is not recommended. The pressure exerted by the blood pressure cuff can obstruct lymphatic flow and contribute to lymphedema.
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