The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?

“The precautions will protect me and help my blood count recover faster."

"Persons entering the room with colds should stay at least 3 feet from me."

"My family plans to bring flowers from my garden to help me feel better."

"Persons entering my room should perform hand hygiene before entering."

Answer and Explanation

The Correct Answer is D

A. “The precautions will protect me and help my blood count recover faster.”: While protective precautions are meant to safeguard the client from infections, this statement does not specifically address the necessary actions or behaviors that need to be followed to maintain reverse isolation. Recovery of blood counts is a complex process that depends on multiple factors, including the underlying condition and treatment.

B. "Persons entering the room with colds should stay at least 3 feet from me.": This statement is not sufficient for reverse isolation. Individuals entering the room should be free of any respiratory illnesses, and maintaining a distance may not be adequate protection. Ideally, anyone entering the room should be healthy and ideally wearing appropriate protective gear, such as masks, to reduce the risk of transmitting infections.

C. "My family plans to bring flowers from my garden to help me feel better.": Bringing flowers from outside can introduce pathogens and compromise the sterile environment necessary for a client in reverse isolation. This statement demonstrates a lack of understanding of the precautions required to maintain a safe environment.

D. "Persons entering my room should perform hand hygiene before entering.": This statement accurately reflects an understanding of the precautions needed in reverse isolation. Hand hygiene is critical in preventing the introduction of pathogens into the sterile environment of a client with a severely depressed neutrophil count. It helps to minimize the risk of infections, which is the primary goal of reverse isolation.

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Correct Answer is A

Explanation

A. Partial thromboplastin time (PTT) 65 seconds: The normal PTT range is typically between 25 to 35 seconds for patients not on anticoagulants. For a patient receiving heparin therapy, the therapeutic PTT range is usually 1.5 to 2.5 times the normal value, which translates to approximately 60 to 100 seconds. A PTT of 65 seconds is at the lower end of the therapeutic range and may require adjustment in dosage or closer monitoring, especially if there are concerns about achieving adequate anticoagulation for the treatment of a pulmonary embolism. It is important to report this value to the provider.

B. Hematocrit 45%: A hematocrit of 45% is within the normal range for adult females (38% to 47%) and males (40% to 54%). This value does not indicate any immediate concern related to heparin therapy or the treatment of a pulmonary embolism.

C. White blood cell count 8.000/mm³: A white blood cell count of 8,000/mm³ is within the normal range (4,500 to 11,000/mm³) and does not indicate any infection or inflammatory process that requires immediate reporting.

D. Platelets: The specific platelet count value is not provided. However, heparin therapy can lead to thrombocytopenia (low platelet count), so if the platelet count is below 150,000/mm³, it should be reported to the provider. Without the specific value, it is not possible to determine if this requires reporting.

A. The vein appears cordlike. B. Purulent drainage is noted from the site. C. The client reports numbness at the site. D. Skin over the site is sloughing.

Correct Answer is B

Explanation

A. The vein appears cordlike: A cordlike appearance of the vein can indicate phlebitis or thrombosis rather than an infection. While this finding may be associated with complications related to an IV catheter, it does not specifically indicate an infection at the insertion site.

B. Purulent drainage is noted from the site: The presence of purulent drainage is a clear sign of infection. Purulent drainage typically indicates the accumulation of pus, which is a result of the body's immune response to infection. This finding aligns with the expectation of an infection at the IV catheter insertion site.

C. The client reports numbness at the site: Numbness is not a common symptom of infection. It may indicate nerve involvement or irritation, which could be related to the placement of the catheter, but it does not directly signify an infection at the insertion site.

D. Skin over the site is sloughing: Sloughing skin may indicate severe tissue damage or necrosis, which could occur in cases of severe infection, but it is not a typical finding in a localized infection at the insertion site. More commonly, an infection would present with redness, warmth, swelling, and possibly purulent drainage.

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The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?

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