Standard precautions are established by the Center for Disease Control (CDC) How would a nurse explain when standard precautions are to be used with a client?
Standard precautions are to be used for any client, regardless of whether an infection has been identified.
Standard precautions are used when the client has an infection that is transmitted on air currents.
Standard precautions are to be used when the client has a pathogen that can spread via moist droplets.
Standard precautions are only used when there is an infection that is spread by indirect contact with an organism.
The Correct Answer is D
Choice A rationale:
Checking a restrained patient every 45 minutes might be too frequent and could interfere with the patient's rest and comfort, especially if the restraint is necessary for their safety. It could also lead to increased agitation and resistance from the patient, making it more challenging for the healthcare providers to manage the situation effectively.
Choice B rationale:
Checking on a restrained patient every 30 minutes is also too frequent for the reasons mentioned above. Patients need some time to rest and recover, and constant monitoring might be perceived as intrusive and threatening, potentially escalating the situation.
Choice C rationale:
Checking on a restrained patient every hour might not be sufficient, especially if the patient is at high risk of harming themselves or others. Waiting for an hour between checks could lead to dangerous situations, as a lot can happen in that time frame.
Choice D rationale:
Checking on a restrained patient every 2 hours strikes a balance between ensuring the patient's safety and respecting their privacy and comfort. It allows healthcare providers to monitor the patient's condition and intervene promptly if necessary while also giving the patient some space to rest and recover.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Keeping the walker at the end of the bed is inconvenient and increases the risk of falls. The walker should be easily accessible, ideally placed near where the client gets up from bed, to provide immediate support.
Choice B rationale: Fluorescent ceiling lights can be too harsh and cause glare, making it difficult for the client to see properly at night. Instead, using a nightlight or a softer, dimmable light source is recommended to provide safe, clear visibility.
Choice C rationale: Placing an area rug at the entry of the bathroom poses a tripping hazard. Loose rugs can easily shift and cause falls. It's better to use non-slip mats or secure carpeting to ensure safe footing, especially in areas prone to moisture.
Choice D rationale: Using a bath seat in the shower reduces the risk of slipping and falling. It provides a stable and secure place to sit while bathing, which is particularly important for clients with a history of falls or limited mobility.
Correct Answer is B
Explanation
Choice A rationale:
Using a fire extinguisher should not be the nurse's first action in this situation. The nurse's priority is to ensure the safety of the clients and staff in the vicinity. Attempting to use a fire extinguisher might not be effective and can potentially cause harm, especially if the fire spreads quickly.
Choice B rationale:
Activating the fire alarm is the nurse's priority in this situation. By activating the fire alarm, the nurse can alert everyone in the facility about the fire, ensuring that people are aware and can evacuate safely. This action initiates the facility's fire response protocol, leading to a quicker and organized response to the emergency.
Choice C rationale:
Moving clients to safety is important, but it is not the nurse's immediate priority in this situation. Activating the fire alarm should be done first to ensure that everyone in the facility is aware of the danger, and then the nurse can assist in moving clients to safety if necessary.
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