A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles.
For which of the following actions by the newly licensed nurse should the charge nurse intervene?
The nurse places the client on airborne precautions.
The nurse has the client wear a mask for transport to radiology.
The nurse wears an N95 respirator when performing client care.
The nurse ensures the client's room maintains a positive airflow.
The Correct Answer is D
A. The nurse places the client on airborne precautions: This is appropriate, as measles is transmitted via airborne particles. B. The nurse has the client wear a mask for transport to radiology: This is correct. A surgical mask minimizes the risk of spreading airborne pathogens during transport. C. The nurse wears an N95 respirator when performing client care: Correct. An N95 respirator is necessary for protection against airborne diseases like measles. D. The nurse ensures the client's room maintains a positive airflow: This is incorrect and requires intervention. Clients with airborne infections like measles must be placed in negative pressure rooms, which prevent contaminated air from escaping into other areas. Positive airflow increases the risk of transmission to others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A child who has mononucleosis and reports severe fatigue requires medical attention, but this condition does not pose an immediate life-threatening risk compared to acute epiglottitis. Mononucleosis is a viral infection that can cause fatigue, sore throat, and swollen lymph nodes. While the child should be assessed, the priority is given to the child with acute epiglottitis due to the potential for airway obstruction and respiratory distress.
Choice B rationale:
A child who has Wilms' tumor and an abdominal mass also needs urgent medical evaluation. Wilms' tumor is a rare kidney cancer that primarily affects children. While it requires prompt attention, acute epiglottitis poses a more immediate threat to the airway and breathing.
Choice C rationale:
A child with acute epiglottitis and drooling requires immediate assessment and intervention. Acute epiglottitis is a potentially life-threatening infection that can cause severe swelling of the epiglottis, leading to airway obstruction. The child may have difficulty breathing and may present with the classic drooling sign due to the inability to swallow saliva. Prompt medical intervention, including airway management and appropriate antibiotics, is essential in this situation.
Choice D rationale:
A child with a urinary tract infection and bright red blood in her urine requires medical evaluation, but this condition is not as urgent as acute epiglottitis. Hematuria (blood in the urine) can have various causes, including urinary tract infections or kidney stones. While the child should receive medical attention, it does not take precedence over the immediate threat posed by acute epiglottitis, which requires urgent intervention to maintain the airway.
Correct Answer is B
Explanation
A is incorrect because the completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.
B is correct because the time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.
C is incorrect because the reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.
D is incorrect because the notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.
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