A nurse in the Medical-Surgical unit is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Airborne.

Contact.

Droplet.

Protective.

Answer and Explanation

The Correct Answer is B

The correct answer is: d. Protective. Protective precautions are crucial for clients who have had an allogeneic hematopoietic stem-cell transplant due to their severely weakened immune systems.

Choice A reason:

Airborne precautions are used for infections that spread through the air, such as tuberculosis and measles. These infections require special ventilation and respiratory protection, which is not the primary concern for stem-cell transplant patients.

Choice B reason:

Contact precautions are used for infections spread by direct contact, like MRSA or C. difficile. These precautions involve wearing gloves and gowns but do not address the airborne or droplet risks that immunocompromised patients face.

Choice C reason:

Droplet precautions are for infections spread by large respiratory droplets, such as influenza or pertussis. While important, they do not provide the comprehensive protection needed for stem-cell transplant recipients.

Choice D reason:

Protective precautions involve placing the patient in a room with HEPA filtration and limiting visitors to minimize infection risk. This is essential for patients with compromised immune systems, such as those who have undergone allogeneic hematopoietic stem-cell transplants.

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Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

Dyspnea (shortness of breath) is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease characterized by the destruction of lung tissue, leading to reduced lung elasticity and airflow limitation, which can result in difficulty breathing.

Choice B rationale:

Clubbing of the fingers is another expected finding in clients with advanced emphysema. Clubbing is the swelling and rounding of the fingertips, often associated with chronic respiratory conditions. It is thought to be a result of chronic hypoxia and inadequate oxygenation.

Choice C rationale:

Deep respirations are not typically associated with emphysema. Clients with emphysema often exhibit shallow, rapid respirations due to the loss of lung tissue elasticity, which impairs the normal respiratory mechanics.

Choice D rationale:

Bradycardia (slow heart rate) is not a common finding in emphysema. Emphysema primarily affects the respiratory system and does not directly influence heart rate. Bradycardia could be related to other factors but is not a characteristic finding of emphysema.

Choice E rationale:

Barrel chest is a classic physical finding in clients with emphysema. It results from the hyperinflation of the lungs due to the trapping of air in the damaged alveoli. This gives the chest a rounded appearance, similar to the shape of a barrel.

A. Respiratory rate. B. Temperature. C. Pulse rate. D. BP.

Correct Answer is B

Explanation

Choice A rationale:

Re-measuring the respiratory rate is unnecessary. The reported respiratory rate falls within the normal range of 12-20 breaths per minute for adults.

Choice B rationale:

Re-measuring the temperature is the correct action. Tympanic temperature measurements can be influenced by factors such as earwax buildup, ear infection, or improper placement of the thermometer. Repeating the temperature measurement ensures accuracy.

Choice C rationale:

Re-measuring the pulse rate is unnecessary. The reported pulse rate of 92 beats per minute falls within the normal range of 60-100 beats per minute for adults.

Choice D rationale:

Re-measuring the blood pressure is unnecessary. The reported blood pressure of 88/58 mm Hg, while at the lower end of the normal range (typically around 90/60 mm Hg), is not excessively low and doesn't indicate an immediate need for concern.

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A nurse in the Medical-Surgical unit is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to see in this client? (Select all that apply.).

Correct Answer is ["A","B","E"]

Explanation

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Correct Answer is B

Explanation

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