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 B
Explanation
B. It acknowledges that recovery is not a quick fix or a one-time event but rather a lifelong journey that involves ongoing effort, self-awareness, and personal growth. Recognizing that recovery occurs in steps suggests an understanding of the incremental progress and challenges that may be encountered along the way.
A. This statement demonstrates some understanding of the concept of recovery from alcohol abuse, but it may not fully reflect the comprehensive nature of recovery.
C. Al-Anon is a mutual support program for people affected by someone else's alcoholism, typically family members and friends. This does not directly involve the client.
D. Detoxification, or the process of clearing alcohol and its byproducts from the body, is an important initial step in recovery, but it is not synonymous with recovery itself.
Correct Answer is A
Explanation
A. Turkey contains tryptophan, which can have a calming effect and aid in sleep, while cheese provides calcium, and milk is a good source of protein and hydration.
B. Fried foods can be heavy and may exacerbate agitation or restlessness. Additionally, mashed potatoes are high in simple carbohydrates, which may cause rapid spikes and crashes in energy levels.
C. Chips are typically high in unhealthy fats and low in essential nutrients, and cola provides little to no nutritional value while containing high amounts of sugar and caffeine, which may exacerbate symptoms of mania.
D. Caffeine content in tea may not be ideal for someone experiencing mania, as it can further stimulate agitation or hyperactivity.
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