This is the edited text:
Which of the following clients should be placed in isolation for airborne precautions?
A client with an unknown skin infection
A client that recently traveled and developed a fever with cough
A high school wrestling champion with a rash
A client with heart palpitations
The Correct Answer is B
Choice A reason: This is not the correct answer because a skin infection is not transmitted by airborne droplets. A skin infection is usually caused by bacteria, fungi, or parasites that invade the skin and cause inflammation, redness, itching, or pus. A skin infection can be contagious by direct contact with the infected area or by sharing personal items, such as towels, clothing, or razors. The client with a skin infection should be placed in isolation for contact precautions, which involve wearing gloves and gowns and using disposable equipment.
Choice B reason: This is the correct answer because a fever with cough can be a sign of a respiratory infection that is transmitted by airborne droplets. A respiratory infection is caused by viruses, bacteria, or fungi that infect the lungs, throat, or nose and cause symptoms such as fever, cough, sore throat, or difficulty breathing. A respiratory infection can be contagious by inhaling the tiny droplets that are released when the infected person coughs, sneezes, or talks. The client with a respiratory infection should be placed in isolation for airborne precautions, which involve wearing a respirator mask and placing the client in a negative pressure room.
Choice C reason: This is not the correct answer because a rash is not transmitted by airborne droplets. A rash is a change in the color, texture, or appearance of the skin that can be caused by various factors, such as allergies, infections, medications, or injuries. A rash can be contagious by direct contact with the affected skin or by sharing personal items, such as clothing, bedding, or sports equipment. The client with a rash should be placed in isolation for contact precautions, which involve wearing gloves and gowns and using disposable equipment.
Choice D reason: This is not the correct answer because heart palpitations are not transmitted by airborne droplets. Heart palpitations are the sensation of having a fast, irregular, or pounding heartbeat that can be caused by various factors, such as stress, anxiety, caffeine, nicotine, or heart conditions. Heart palpitations are not contagious and do not require isolation. The client with heart palpitations should be evaluated for the underlying cause and treated accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A bone fragment has injured the nerve supply in the area is not the best response by the nurse. This may be a possible complication of a fracture, but it does not explain the mechanism of compartment syndrome. Compartment syndrome is a condition where the pressure within a closed space (such as a muscle compartment) exceeds the perfusion pressure and causes ischemia and necrosis of the tissues. A bone fragment may damage the nerve, but it does not cause increased pressure in the compartment.
Choice B reason: An injured artery causes impaired arterial perfusion through the compartment is not the best response by the nurse. This may be a possible cause of compartment syndrome, but it is not the most common one. Compartment syndrome is more often caused by venous obstruction than arterial obstruction. An injured artery may reduce the blood flow to the compartment, but it does not cause increased pressure in the compartment.
Choice C reason: Bleeding and swelling cause increased pressure in an area that cannot expand is the best response by the nurse. This is the most common cause of compartment syndrome and explains the pathophysiology of the condition. Bleeding and swelling are the result of inflammation and tissue injury that occur after a fracture. They increase the volume of fluid in the compartment, which cannot expand due to the rigid fascia that surrounds it. This leads to increased pressure in the compartment, which compresses the blood vessels, nerves, and muscles and causes ischemia and necrosis of the tissues.
Choice D reason: The fascia expands with injury, causing pressure on underlying nerves and muscles is not the best response by the nurse. This is not a correct statement, as the fascia does not expand with injury. The fascia is a tough connective tissue that encloses the muscle compartments and limits their expansion. The fascia is part of the problem, not the cause, of compartment syndrome. The fascia prevents the compartment from accommodating the increased volume of fluid and causes increased pressure in the compartment.
Correct Answer is C
Explanation
Choice A reason: A 44yearold prescribed antibiotics for pneumonia is not at the greatest risk for pressure injury development, because he or she does not have any major risk factors for pressure injury. Pressure injury is a localized damage to the skin and underlying tissues caused by pressure, shear, friction, or moisture. Antibiotics for pneumonia do not directly affect the skin integrity or blood circulation, nor do they impair the mobility or sensation of the client.
Choice B reason: A 26yearold bedridden client with a fractured leg is at a high risk for pressure injury development, but not the greatest, because he or she has only one major risk factor for pressure injury. Bedridden status is a major risk factor for pressure injury, because it causes prolonged pressure on the bony prominences, such as the sacrum, heels, or hips, which can impair blood flow and oxygen delivery to the skin and tissues. However, the client's age, fracture, and mobility may mitigate some of the risk, as he or she may have better skin elasticity, wound healing, and ability to reposition.
Choice C reason: A 65yearold with hemiparesis and incontinence is at the greatest risk for pressure injury development, because he or she has multiple major risk factors for pressure injury. Age is a risk factor for pressure injury, because it causes decreased skin elasticity, thickness, and vascularity, which can affect the skin's resilience and repair. Hemiparesis is a risk factor for pressure injury, because it causes reduced mobility, sensation, and muscle mass, which can affect the client's ability to reposition, feel pain, and maintain tissue perfusion. Incontinence is a risk factor for pressure injury, because it causes moisture, irritation, and infection of the skin, which can weaken the skin barrier and delay wound healing.
Choice D reason: A 78yearold requiring assistance to ambulate with a walker is at a moderate risk for pressure injury development, but not the greatest, because he or she has only one major risk factor for pressure injury. Age is a risk factor for pressure injury, as explained above. However, the client's ambulation and assistance may reduce some of the risk, as he or she may have less pressure, shear, and friction on the skin and tissues, and more blood circulation and oxygen delivery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today