A nurse is teaching a client who is immunocompromised and requires a protective environment. Which of the following statements should the nurse make?
"You should wear a sterile gown when outside of your room."
"You'll share a room with a client who is also immunocompromised."
"You are required to wear an N95 respirator mask."
"You will be placed in a positive-pressure airflow room."
The Correct Answer is D
A. "You should wear a sterile gown when outside of your room." While protective clothing may be required in certain cases, wearing a sterile gown outside the room is not a standard recommendation for immunocompromised clients.
B. "You'll share a room with a client who is also immunocompromised." Clients who require a protective environment should be placed in a private room to minimize the risk of exposure to infections.
C. "You are required to wear an N95 respirator mask." N95 respirators are typically required for healthcare workers caring for clients with airborne precautions, not for immunocompromised clients in a protective environment.
D. "You will be placed in a positive-pressure airflow room." A positive-pressure room helps keep airborne pathogens out by ensuring that air flows out of the room rather than into it, reducing the risk of infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client if they understand the procedure. The nurse’s role in informed consent is to confirm that the client understands the procedure and voluntarily agrees to it. If the client has questions or does not understand, the nurse should notify the provider for further explanation.
B. Describe the procedure to the client. It is the provider’s responsibility to explain the procedure in detail, including what it entails. The nurse should not provide this explanation.
C. Inform the client about alternative treatment options. The provider must discuss alternative treatment options, not the nurse. The nurse can ensure that this discussion has occurred but does not provide the alternatives.
D. Explain the risks of the procedure to the client. The provider is responsible for explaining the risks, benefits, and expected outcomes of the procedure. The nurse’s role is to witness the consent and ensure the client understands.
Correct Answer is ["A","B","C"]
Explanation
Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.
Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.
Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.
Other Findings:
Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.
Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.
Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.
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