A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (Select all that apply.)

Emptying a urinary drainage bag for a client who has pneumonia

Suctioning a client's new tracheostomy tube

Irrigating a client's abdominal wound

Providing hygiene care to a client who is HiV-positive

Transporting a cerebrospinal fluid specimen to the Laboratory

Answer and Explanation

Correct Answer : B,C

A) Emptying a urinary drainage bag for a client who has pneumonia:
Wearing protective eye equipment is not necessary for emptying a urinary drainage bag. Standard precautions for handling bodily fluids would apply, but there is no expected risk for splashes to the eyes when performing this task. Gloves and hand hygiene are essential, but eye protection is not typically required.

B) Suctioning a client's new tracheostomy tube:
When suctioning a client's tracheostomy tube, there is a significant risk of splashing or spraying bodily fluids, including mucus, that may contain infectious particles. Wearing protective eye equipment is necessary to prevent potential contamination of the eyes from bodily fluids during this procedure. This is a high-risk task for exposure.

C) Irrigating a client's abdominal wound:
Irrigating an abdominal wound carries a risk of splashing bodily fluids, particularly when fluids are under pressure or if the wound is large. To avoid exposure to infectious material, the nurse should wear protective eye equipment to prevent any risk of fluids coming into contact with the eyes.

D) Providing hygiene care to a client who is HIV-positive:
Providing hygiene care to a client who is HIV-positive does not pose a significant risk to the nurse’s eyes, as HIV is transmitted through blood and certain body fluids under specific conditions. While gloves and other precautions are necessary, protective eye equipment is not required for standard hygiene care unless there is a specific risk of splashing.

E) Transporting a cerebrospinal fluid specimen to the laboratory:
When transporting cerebrospinal fluid (CSF), the primary concern is ensuring the specimen is properly contained to prevent leaks or spills. While gloves should be worn to handle the specimen, there is no direct risk of exposure to the eyes unless there is a spill. In such a case, the nurse would need to protect their eyes, but wearing protective eyewear during transport is not routinely required.

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

Explanation

A) Foot drop: Foot drop is a common complication associated with impaired physical mobility. It occurs when the muscles responsible for lifting the front of the foot become weak or paralyzed, often due to prolonged immobility or neurological impairment. The nurse should monitor for this condition and implement preventive measures like using ankle-foot orthoses (AFOs) to support the foot in a neutral position and promote proper alignment.

B) Increased socialization: While it is important to encourage socialization and support mental health, increased socialization is not a complication associated with impaired mobility. In fact, patients with impaired mobility are more likely to experience social isolation, not increased socialization. Therefore, the nurse should focus on strategies to encourage social interaction to prevent feelings of loneliness and depression.

C) Somnolence: Somnolence, or excessive sleepiness, is not directly related to impaired physical mobility. While some patients with severe illness or conditions may experience somnolence, it is not a common complication of immobility. Instead, the nurse should focus on monitoring for complications like respiratory issues or skin breakdown.

D) Hypostatic pneumonia: Hypostatic pneumonia is a complication that can occur when a patient remains in a supine or immobile position for an extended period. The lack of movement and deep breathing can lead to pooled secretions in the lungs, which increases the risk of infection. The nurse should monitor for signs of respiratory distress and encourage frequent position changes, deep breathing, and coughing exercises to reduce the risk.

E) Impaired skin integrity: Impaired skin integrity is a major concern in patients with impaired mobility. Prolonged pressure on bony prominences due to immobility can lead to pressure ulcers (bedsores). The nurse should monitor the skin regularly, implement pressure-relieving devices, and reposition the patient frequently to prevent skin breakdown.

A. Droplet B. Contact C. Airborne D. Protective environment

Correct Answer is C

Explanation

A) Droplet: Droplet precautions are used for infections that spread through respiratory droplets when an infected person coughs, sneezes, or talks. While measles is transmitted through respiratory droplets, the virus is highly contagious and requires airborne precautions, not just droplet precautions.

B) Contact: Contact precautions are used for infections spread through direct contact with the patient or their environment, such as gastrointestinal or skin infections. Measles is primarily spread through the air and is not classified as a contact transmission infection.

C) Airborne: Measles is an airborne illness, which means that it can be transmitted through small respiratory droplets that remain suspended in the air for long periods of time. Airborne precautions are necessary to protect healthcare workers and other patients from exposure. These precautions include placing the child in a negative pressure room and requiring healthcare workers to wear N95 respirators.

D) Protective environment: Protective environment precautions are used for patients with severely weakened immune systems, such as those undergoing chemotherapy or organ transplantation. These precautions are designed to protect the patient from infections, not to prevent the spread of contagious illnesses like measles.

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A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (Select all that apply.)

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