The nurse should utilize what type of precaution when palpating the lips in a healthy adult?
Contact precautions.
Airborne precautions.
Standard precautions.
Droplet precautions.
The Correct Answer is C
Standard precautions refer to the basic infection prevention measures that should be taken with all patients, regardless of their known or suspected infection status. This includes hand hygiene, the use of personal protective equipment (such as gloves), and the proper handling and disposal of contaminated items.
If there is a concern for an infection, additional precautions may be necessary based on the suspected or confirmed pathogen. In such cases, the nurse should follow transmission-based precautions, which are specific measures designed to prevent the spread of certain types of infections. For example, if there is a concern for a respiratory infection such as influenza, the nurse may need to use droplet precautions, which would include wearing a mask in addition to standard precautions.
It's important for the nurse to assess the patient's medical history and current condition to determine what precautions are necessary. The nurse should also be aware of and follow the infection control policies and procedures of their healthcare facility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The nurses would teach the patient to palpate all four quadrants of the breast, including the upper outer quadrant, lower inner quadrant, and upper inner quadrant, as well as the tail of Spence, which is the extension of breast tissue into the axilla (armpit). It's important for the patient to be familiar with their own breast tissue and report any changes or abnormalities to their healthcare provider.
Correct Answer is B
Explanation
Auscultating breath sounds is an essential component of a respiratory assessment. The following breath sounds can be heard during auscultation: Vesicular, Bronchial, Bronchovesicular, Crackles, Wheezes, and Rhonchi.
Vesicular sounds at the apex of the lungs (a) and vesicular sounds at the base of the lungs on the posterior chest (c) are normal findings. Vesicular sounds are soft and low-pitched, heard during inspiration, and are indicative of air moving through small airways and alveoli. The vesicular sounds are louder at the base of the lungs, where there is more alveolar tissue.
Rhonchi that disappear with coughing (d) can be normal or abnormal findings. Rhonchi are low-pitched, continuous sounds that are heard during inspiration and expiration. They are produced by the movement of air through narrowed or obstructed airways. If the rhonchi disappear with coughing, it may indicate that the airway has cleared.
Wheezes on inspiration (b) are abnormal findings and require prompt follow-up. Wheezes are high-pitched, whistling sounds heard during inspiration and expiration. They are indicative of air moving through narrowed airways and can be a sign of an underlying respiratory condition such as asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. Prompt follow-up is necessary to diagnose and manage the underlying condition.
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