A nurse is planning care for a toddler who has measles. Which of the following isolation precautions should the nurse initiate?
Contact
Airborne
Protective
Droplet
The Correct Answer is B
Rationale
A. Contact: Contact precautions are used for infections spread by direct or indirect contact, such as C. difficile or MRSA. Measles is not primarily transmitted via contact, so contact precautions alone are insufficient.
B. Airborne: Measles is highly contagious and transmitted via airborne respiratory droplets that can remain suspended in the air. Airborne precautions, including placing the client in a negative-pressure room and requiring staff to wear N95 respirators, are necessary to prevent transmission.
C. Protective: Protective (or neutropenic) precautions are designed to protect immunocompromised clients from infection. They are not appropriate for preventing the spread of measles from an infected client.
D. Droplet: Droplet precautions are used for infections spread by larger respiratory droplets, such as influenza or pertussis. Measles requires airborne precautions because the virus can travel on smaller particles and remain suspended in the air for extended periods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. Ask the client to occlude one ear with a finger: Occluding one ear is part of the Rinne test, not the Weber test. The Weber test assesses lateralization of sound and does not require the client to block either ear initially.
B. Place a vibrating tuning fork against the midline vertex of the client's head: In the Weber test, the vibrating tuning fork is placed on the midline of the skull, usually the forehead or vertex. This allows the nurse to assess whether sound is heard equally in both ears or lateralizes to one, helping differentiate between conductive and sensorineural hearing loss.
C. Whisper words for the client to identify: Whispered voice testing evaluates the client’s ability to hear and repeat words, but it is a separate assessment from the Weber test and does not determine lateralization.
D. Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden: This describes the whispered voice or speech discrimination test, not the Weber test. The Weber test focuses on bone conduction and sound lateralization rather than speech comprehension.
Correct Answer is B,A,E,D,C
Explanation
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