The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?
Change bed linens on a daily basis.
Provide fresh drinking water every four hours.
Restrict visitors who have an upper respiratory infection.
Monitor intake and output every shift.
The Correct Answer is C
C. This is the priority intervention because clients in protective isolation have compromised immune systems and are at high risk of infection. Upper respiratory infections can be transmitted easily through respiratory droplets, posing a significant risk to the client. Restricting visitors with such infections helps minimize the risk of introducing pathogens into the client's environment.
A. While maintaining cleanliness is important in any healthcare setting, changing bed linens daily may not be the highest priority in protective environment isolation unless there is a specific indication (e.g., soiled linens, contamination). It is essential to minimize unnecessary contact and potential sources of infection, but this is not the priority in the given context.
B. Hydration is important for all clients, but the frequency of providing fresh drinking water every four hours is generally a routine nursing care measure. Unless there are specific medical orders or client needs, this action is not directly related to the specialized care required in protective environment isolation.
D. Monitoring intake and output is important for assessing fluid balance and kidney function in hospitalized clients. However, in the context of protective isolation, where infection control is paramount, restricting visitors who pose a potential infectious risk takes precedence over routine monitoring tasks.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["16"]
Explanation
Total Volume (ml) / Rate (ml/hr) = Time (hr).
For a client receiving 2 liters of IV fluid at a rate of 125 ml/hr,
Convert liters to milliliters (since 1 liter = 1000 ml, therefore 2 liters = 2000 ml). Then, divide the total volume by the rate: 2000 ml / 125 ml/hr = 16 hours.
So, the nurse should expect the IV fluids to last for 16 hours.
Correct Answer is ["A","B","E"]
Explanation
A. This is located on the lateral side of the thigh. It is a commonly used site for infants, toddlers, and young children, as well as adults who require large-volume injections.
B. This site is located on the hip or gluteal region. It is considered one of the safest and least painful sites for intramuscular injections in adults. It is also used when the volume of medication is larger or when the dorsogluteal site is contraindicated.
E. This site is located on the upper arm, specifically the lateral aspect. It is commonly used for vaccines and medications that require smaller volumes in adults and older children.
C. There is no specific muscle called the "rectus lateralis." It seems to be a combination of the rectus femoris (a muscle in the quadriceps group of the thigh) and the vastus lateralis. However, neither "rectus lateralis" nor "rectus femoris" is commonly used as a distinct injection site in clinical practice.
D. This site is located on the buttocks. Historically, it was a commonly used site for intramuscular injections, but it has fallen out of favor due to the potential risk of injury to the sciatic nerve and superior gluteal artery.
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