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
- A. Constipation is not a common complication of vacuum-assisted birth. It may be related to other factors such as dehydration, opioid use, or decreased mobility.
- B. Urinary urgency is not a common complication of vacuum-assisted birth. It may be related to other factors such as bladder trauma, infection, or diuretic use.
- C. Cervical laceration is a common complication of vacuum-assisted birth. It occurs when the vacuum cup causes damage to the cervix during delivery. It can lead to bleeding, infection, or cervical incompetence in future pregnancies.
- D. Retained placenta is not a common complication of vacuum-assisted birth. It may be related to other factors such as placenta accreta, uterine atony, or manual removal of the placenta.
Correct Answer is D
Explanation
pH 7.31
Rationale:
A - This is incorrect because weight gain is not expected in clients who have COPD, as they often have difficulty eating and digesting food due to dyspnea and fatigue.
B - This is incorrect because a decrease in anteroposterior diameter of the chest is not typical of COPD, as the condition causes hyperinflation and air trapping in the lungs, leading to an increase in chest size and a barrel-shaped appearance.
C - This is incorrect because HCO3 24 mEq/L is within the normal range for blood bicarbonate levels, which are 22 to 26 mEq/L. Clients who have COPD often have chronic respiratory acidosis, which stimulates the kidneys to retain bicarbonate and increase its levels in the blood to compensate for the low pH.
D - This is correct because pH 7.31 indicates acidosis, which is common in clients who have COPD due to impaired gas exchange and accumulation of carbon dioxide in the blood.
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