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 C
Explanation
C. Sodium intake can influence lithium excretion and affect serum lithium levels. Maintaining a consistent and adequate sodium intake is important for stabilizing serum lithium levels and optimizing the medication's therapeutic effects.
A. Patients should have their serum lithium levels checked regularly, typically every 3 months, not just every 6 months as suggested.
B. Clients should never adjust their lithium dose without consulting their healthcare provider. Lithium dosage adjustments should be made only under the guidance and supervision of a healthcare professional based on the client's clinical response, serum lithium levels, and overall treatment plan.
D. Adequate hydration is essential for overall health and well-being, and dehydration can increase the risk of lithium toxicity.
Correct Answer is C
Explanation
C. This awareness is crucial because personal emotions can cloud professional judgment, leading to bias in assessing the situation and making decisions. It's important for healthcare professionals to maintain a level of emotional detachment in order to provide the most objective and effective care.
A. Positive feelings alone are not likely to lead to underinvolvement. Instead, the risk lies more in becoming overly empathetic or emotionally attached, which could cloud judgment or compromise professional objectivity.
B. Recognizing and acknowledging one's own feelings while working with families experiencing domestic violence can help prevent emotional burnout and maintain mental well-being. However, this does not relate directly to domestic violence.
D. Experiencing only positive feelings without acknowledging the complexities and challenges of the situation may hinder the nurse's ability to provide comprehensive care and support to the victim.
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