44) A nurse is teaching a newly licensed nurse about implementing droplet precautions for a client who has influenza. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
“I will wear a surgical mask within 3ft of the client”
“I will check that the room has a high-efficiency particulate air filtration system”
“I will wear an N95 respirator when providing care for the client”
“I will assign the client to a room with positive airflow”
The Correct Answer is A
Rationale:
a. Droplet precautions require healthcare workers to wear a surgical mask when within 3 feet of the client to prevent the transmission of respiratory droplets containing infectious agents like influenza.
b. While high-efficiency particulate air (HEPA) filtration systems can help improve air quality, they are not specifically required for implementing droplet precautions.
c. N95 respirators are typically reserved for airborne precautions, which are not indicated for influenza.
d. Assigning the client to a room with positive airflow is not necessary for implementing droplet precautions; standard precautions such as wearing a surgical mask are sufficient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b. While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c. Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d. The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.
Correct Answer is C
Explanation
a. Green tags are used for the "walking wounded" who will need medical care at some point after more critical injuries have been treated. This would not be appropriate for a client with full thickness burns on 72% of his body, as this condition is life-threatening and requires immediate attention.
b. Yellow tags are for those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. This client's condition, however, is too critical for a yellow tag.
c. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
d. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
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