A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

Standard

Airborne

Droplet

Contact

Answer and Explanation

The Correct Answer is A

Choice A reason : Standard precautions are the primary strategy for the prevention and control of hepatitis C virus (HCV) transmission. According to the Centers for Disease Control and Prevention (CDC), standard precautions include hand hygiene and the use of personal protective equipment to prevent contact with blood and other potentially infectious materials¹. Since HCV is primarily transmitted through blood-to-blood contact, standard precautions are sufficient for routine care of patients with hepatitis C².

Choice B reason : Airborne precautions are not necessary for hepatitis C as it is not spread through the air. These precautions are used for diseases that are transmitted through airborne droplet nuclei or dust particles containing the infectious agent, such as tuberculosis, measles, or chickenpox¹.

Choice C reason : Droplet precautions are also not required for hepatitis C because it is not spread through droplets in the air. Droplet precautions are used for infections that can be transmitted through large droplets expelled during coughing, sneezing, talking, or during procedures such as suctioning and bronchoscopy¹.

Choice D reason : Contact precautions are not specifically required for hepatitis C unless there is a risk of blood contamination. Contact precautions are typically used for infections that are spread by direct or indirect contact with the patient or the patient's environment, such as gastrointestinal, respiratory, skin, or wound infections¹.

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Correct Answer is B

Explanation

Choice A reason :While consulting with the healthcare provider is important, immediate action is necessary to prevent harm. Waiting for a prescription may delay intervention.

Choice B reason : When a patient frequently attempts to remove their intravenous (IV) catheter, it's essential to address the behavior promptly to prevent potential complications such as catheter dislodgement, infection, or injury. The most appropriate initial response is to cover the catheter to reduce the patient's awareness and access, thereby decreasing the likelihood of tampering.

Choice C reason : Providing more stimulation could be counterproductive if the client is already agitated or confused. The nurse should assess the client's needs and environment to determine the appropriate level of stimulation.

Choice D reason : Waiting without taking action is not advisable as the client may harm themselves by removing the IV catheter. Immediate intervention is required to ensure the client's safety.

A. The provider will be coming to explain the situation. B. "I reported the incident to my supervisor who decided to contact the authorities." C. "As a nurse, I am required by law to report suspected child abuse." D. "I am unable to discuss this, but I can contact my supervisor to speak with you."

Correct Answer is C

Explanation

Choice A reason : While it is true that a healthcare provider may come to explain the situation, this response does not directly address the parent's concern about the reason for the nurse's action. It is important for the nurse to communicate clearly and directly about their responsibilities and the actions they have taken.

Choice B reason : This response indicates that the nurse has taken action by reporting to a supervisor, but it does not clarify the nurse's legal obligation to report suspected child abuse. It is essential for nurses to understand and communicate their role as mandated reporters to ensure transparency and trust in the healthcare setting¹.

Choice C reason : This is the most appropriate response because it directly addresses the parent's question and explains the nurse's legal responsibility. Nurses are mandated reporters and are legally required to report any suspicions of child abuse to protect the child's welfare. This response is clear, direct, and upholds the nurse's professional and legal obligations¹³.

Choice D reason : While contacting a supervisor may be part of the protocol, this response does not provide the parent with an explanation for the nurse's action. It is important for the nurse to explain their legal duty to report suspected child abuse, which is the primary reason for their action.

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A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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