The nurse is caring for a client with a total calcium level of 7.0 mg/dL. To assess for Chvostek's sign, the nurse would:

strain all of the client's urine.

inflate a blood pressure cuff 20 mmHg above systolic measurement.

lightly percuss the client's cheek.

obtain a baseline height and weight.

Answer and Explanation

The Correct Answer is C

C. Chvostek's sign is assessed by tapping or lightly percussing the facial nerve (facial muscles) at the angle of the jaw, just in front of the earlobe. A positive Chvostek's sign is indicated by facial twitching, especially around the mouth, nose, and eye, in response to this percussion. It indicates neuromuscular irritability due to low calcium levels.

A. Straining urine is typically done to collect urine for analysis or to detect urinary stones. It does not relate to the assessment of neuromuscular irritability, which is what Chvostek's sign evaluates.

B. This option does not pertain to assessing Chvostek's sign either. Inflating a blood pressure cuff above systolic measurement is a technique used to assess for Trousseau's sign, which is another clinical indicator of hypocalcemia but involves different physiological mechanisms than Chvostek's sign.

D. This option is unrelated to assessing Chvostek's sign or hypocalcemia. Baseline height and weight are typically obtained for nutritional assessment, growth monitoring, or as part of a general health assessment. They do not help in evaluating neuromuscular irritability associated with calcium levels.

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Correct Answer is C

Explanation

C. This option correctly identifies therationale behind the nurse's instruction. Immunosuppressed clients have a weakened immune system, making them highly vulnerable to infections. Family members may carry microorganisms on their hands, clothes, or respiratory secretions that can potentially transmit infections to the client. Wearing gloves and a mask helps reduce the risk of introducing pathogens to the client.

A. This option suggests that the risk is related to hospital staff transmitting infections to family members. While this is a concern in healthcare settings, it is not directly related to the specific situation described where family members are visiting an immunosuppressed client in a protective environment.

B. This option implies that the hospital environment itself poses a risk of infection transmission to family members. While hospitals can harbor various pathogens, the primary concern in this scenario is the transmission of infections to the immunosuppressed client from outside sources, including family members.

D. This option suggests that the client could transmit infections to family members. While this is theoretically possible depending on the specific infectious agent and the client's condition, the primary concern in a protective environment is preventing infections from entering the client's environment and affecting their health.

A. Place the patient in a negative pressure room. B. Use droplet precautions when the pathogen can be spread via sneezing, coughing or talking. C. Use droplet precautions to control the spread of infections that are transmitted person-to- person on air currents. D. An N-95 mask should be worn. E. Wear a surgical mask when working within 3 feet of the patient.

Correct Answer is ["B","E"]

Explanation

B Droplet precautions are used for pathogens that can be transmitted through respiratory droplets produced when an infected person coughs, sneezes, talks, or during procedures such as suctioning.

E. Healthcare workers should wear a surgical mask when within close proximity (within 3 feet) of a patient on droplet precautions. The mask helps prevent the inhalation of droplets that may contain infectious pathogens.

A. Negative pressure rooms are used for airborne precautions, not droplet precautions. Droplet precautions typically do not require negative pressure rooms.

C. Infections transmitted on air currents are managed with airborne precautions, not droplet precautions. Droplet transmission occurs over shorter distances (generally within 3 feet) due to larger respiratory droplets.

D. An N-95 mask is used for airborne precautions to filter smaller particles. For droplet precautions, healthcare workers typically wear a surgical mask to protect against larger respiratory droplets.

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The nurse is caring for a client with a total calcium level of 7.0 mg/dL. To assess for Chvostek's sign, the nurse would:

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Naxlex Comprehensive Predictor Exams

The nurse is instructing family members of an immunosuppressed client who has been placed in a protective environment to wear gloves and a mask when visiting the client. The nurse is aware that this practice is important to prevent infection transmission from:

Correct Answer is C

Explanation

A nurse educator is teaching student nurses about droplet precautions. The educator emphasizes the differences between indications for droplet precautions versus airborne precautions. Which of the following statements about droplet precautions are correct? (SELECT ALL THAT APPLY)

Correct Answer is ["B","E"]

Explanation

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