The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?
Initiate droplet precautions
Initiate airborne precautions
Place the client in a positive pressure room
Initiate neutropenic precautions
The Correct Answer is B
B. Airborne precautions are used for diseases that can be transmitted through tiny respiratory droplets that remain in the air for extended periods. Examples include tuberculosis and measles. Given the symptom of coughing up blood and the possibility of an infectious respiratory disease, initiating airborne precautions could be warranted.
A. Droplet precautions are typically implemented for diseases that spread through respiratory droplets, such as influenza or pertussis. However, coughing up blood suggests a more serious condition that may not be adequately addressed by droplet precautions alone.
C. Positive pressure rooms are typically used in healthcare settings to prevent outside air from entering the room, thus reducing the risk of airborne contaminants. While this measure can be beneficial for certain conditions, such as those requiring airborne precautions, it may not be the priority intervention.
D. Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). While this precaution is important for protecting immunocompromised patients from infections, it may not be the priority intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Domestic violence is not simply about physical violence but also involves an imbalance of power where the abuser seeks to exert control over the victim through various means, including emotional, psychological, financial, and social manipulation.
B. Domestic violence can certainly lead to erratic relationships and exacerbate feelings of vulnerability but this statement does not capture the central dynamic of power and control that characterizes domestic violence.
C. Poor communication and social isolation can be contributing factors in some cases of domestic violence but they are not necessarily central to the dynamic.
D. This statement partially captures the psychological impact of domestic violence on victims, including emotional injury and learned helplessness. However, it does not explicitly address the underlying dynamic of power and control.
Correct Answer is C
Explanation
C. Bringing birth certificates and Social Security cards is essential for establishing identity and accessing necessary services, such as shelters, legal assistance, or government benefits. These documents may be needed for applying for assistance, obtaining housing, or enrolling children in school.
A. Ensuring the well-being and comfort of any children involved is important but bringing toys to amuse them for a few days may not be the highest priority when creating an escape plan from spousal abuse.
B. A cell phone can be used to call for help, contact emergency services, or reach out to trusted individuals for assistance. However, it is not the most important item.
D. Having reading materials may provide distraction and comfort during stressful times but they are not typically considered essential items for an escape plan from spousal abuse.
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