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 C
Explanation
Choice A rationale:
Pulse pressure is the difference between systolic and diastolic blood pressure and is not related to changing positions or the symptoms described in the scenario.
Choice B rationale:
Essential hypertension is a chronic medical condition characterized by elevated blood pressure levels persistently exceeding 140/90 mmHg. It is not directly related to positional changes or postural hypotension symptoms.
Choice C rationale:
Postural (orthostatic) hypotension occurs when a person experiences a sudden drop in blood pressure upon standing up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, and fainting. Slowly changing positions is essential in managing postural hypotension because abrupt movements can worsen these symptoms. Educating the client about the importance of gradual position changes is crucial in preventing or minimizing postural hypotension-related symptoms.
Choice D rationale:
Pre-hypertension refers to blood pressure levels that are higher than normal but not high enough to be diagnosed as hypertension. It does not directly relate to the symptoms described in the scenario.
Correct Answer is B
Explanation
Choice A rationale:
Providing the AP with the appropriate PPE (Choice A) is a good immediate action, but it does not address the issue comprehensively. It is crucial to report the incident to the higher authorities to ensure that appropriate measures are taken to prevent similar occurrences in the future.
Choice B rationale:
Notifying the charge nurse about the AP's lack of PPE (Choice B) is the most appropriate action in this situation. The charge nurse is responsible for overseeing the staff and ensuring compliance with safety protocols. Reporting the incident to the charge nurse allows for appropriate disciplinary action, additional training, or reminders about infection control procedures to prevent future violations.
Choice C rationale:
Volunteering to provide an in-service about infection control (Choice C) is a positive initiative, but it might not address the immediate issue at hand. While education is essential, the pressing matter is the AP's violation of infection control protocols, which needs to be reported promptly to the charge nurse.
Choice D rationale:
Speaking with the AP before leaving the shift about the appropriate protocol (Choice D) is insufficient on its own. While educating the AP about the correct protocols is essential, it should not replace reporting the incident to the charge nurse. Reporting ensures that appropriate actions are taken to maintain a safe environment for both healthcare workers and patients.
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