A nurse is teaching a group of assistive personnel about airborne precautions. Which of the following statements should the nurse make when caring for a client who has the measles?
A mask is not required when more than 3 feet from a client who requires airborne precautions.
A client who has varicella should be placed in a positive pressure room.
A respirator should be worn when entering the client's room.
A gown and gloves should be worn when providing direct care to the client.
The Correct Answer is C
Choice A reason: A mask is not sufficient to protect against airborne pathogens, such as the measles virus. A mask only filters out large droplets, but not the small particles that can remain suspended in the air. A mask should be worn when caring for a client who requires droplet precautions, such as influenza or pertussis.
Choice B reason: A client who has varicella should be placed in a negative pressure room, not a positive pressure room. A negative pressure room prevents the contaminated air from escaping the room and infecting others. A positive pressure room does the opposite: it prevents the outside air from entering the room and contaminating the client. A positive pressure room is used for clients who require protective isolation, such as those who are immunocompromised.
Choice C reason: A respirator should be worn when entering the client's room who has the measles. A respirator is a special type of mask that filters out both large and small particles, and provides a tight seal around the face. A respirator is required for clients who require airborne precautions, such as tuberculosis, varicella, or measles.
Choice D reason: A gown and gloves should be worn when providing direct care to the client who has the measles, but they are not specific to airborne precautions. A gown and gloves are part of standard precautions, which apply to all clients regardless of their diagnosis or infection status. A gown and gloves protect the nurse from contact with the client's blood, body fluids, secretions, and excretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.
B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.
C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.
D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.
Correct Answer is C
Explanation
Choice A reason: Asking the provider to delay the client's discharge home for a few more days is not an appropriate action for the nurse to take. This would not address the partner's concerns or the client's needs. It would also increase the risk of hospital-acquired infections and complications for the client.
Choice B reason: Seeking out another family member to assist the client's partner with care is not an appropriate action for the nurse to take. This would not respect the partner's autonomy or the client's wishes. It would also assume that there is another family member who is willing and able to provide care.
Choice C reason: Contacting a case manager to discuss hospice options is the appropriate action for the nurse to take. This would provide the client and the partner with information and support regarding end-of-life care. Hospice care focuses on improving the quality of life and comfort of clients with terminal illnesses and their families.
Choice D reason: Advising the partner to place the client in a long-term care facility is not an appropriate action for the nurse to take. This would not respect the partner's feelings or the client's preferences. It would also imply that the nurse is judging the partner's decision or ability to care for the client.
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