A nurse on a medical unit is admitting a client.

Exhibits

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Nurses' Notes

Day 1, 1600:

Client admitted from provider's clinic reporting shortness of breath, dry hacking cough, dizziness, and "heart racing."

States they are not able to sleep well on their back at night because of difficulty breathing.

Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 130/min, ECG monitor showing sinus tachycardia, S1, auscultated. Lower extremity edema noted, 2+ bilaterally, Radial and pedal pulses 1+ bilaterally.

Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.

Client reports gaining 10 pounds in the past month.

Reports history of type 2 diabetes mellitus and hypertension.

Answer: D. "Clean the prosthesis using a damp, soapy cloth."

Rationale:

A. "Keep initial pressure dressing in place for 1 week after surgery":
The pressure dressing is typically changed more frequently to monitor the incision site for signs of infection and to ensure appropriate healing. Keeping it in place for a week without monitoring could increase the risk of infection and complications.

B. "Leave the prosthesis in place when going to bed":
It is generally recommended to remove the prosthesis at night to allow the residual limb to rest and prevent skin irritation or pressure sores. Leaving it on overnight can lead to unnecessary strain on the limb.

C. "Avoid extension of the hips when lying down":
Clients should actually avoid prolonged hip flexion, not extension, as it can lead to hip contractures. Instead, they should try to lie prone periodically to stretch the hip and reduce the risk of contracture formation.

D. "Clean the prosthesis using a damp, soapy cloth":
Using a damp, soapy cloth to clean the prosthesis helps maintain hygiene and prevents skin irritation. It's important to keep the prosthesis clean to avoid any buildup of bacteria or dirt, which can affect both the device and the residual limb’s health.

A. Airborne precautions are used for diseases transmitted by tiny particles that remain suspended in the air and are inhaled, such as tuberculosis or measles. Mononucleosis is not spread through
the airborne route.

B. Droplet precautions are for diseases transmitted by respiratory droplets, like influenza or pertussis. While mononucleosis can be transmitted through respiratory secretions, it's primarily spread through direct contact with saliva.
C. Contact precautions involve preventing the transmission of pathogens by direct or indirect contact. Given that mononucleosis is transmitted through saliva, contact precautions, including wearing gloves and gowns, are appropriate to prevent its spread.
D. Protective environment precautions are used to protect immunocompromised patients from outside pathogens, such as those recovering from bone marrow transplants. They are not applicable for a client with mononucleosis.