A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?
Airborne
Contact
Droplet
Protective
The Correct Answer is C
A. Airborne:
Airborne precautions are used for infections transmitted via small droplet nuclei that remain suspended in the air for long periods and can be inhaled by others. Examples of diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. Pertussis is not transmitted via the airborne route.
B. Contact:
Contact precautions are used for infections spread by direct or indirect contact with the client or their environment. Examples include Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Pertussis is primarily spread through respiratory droplets rather than contact with contaminated surfaces.
C. Droplet:
Pertussis is primarily spread through respiratory droplets when an infected person coughs or sneezes. The nurse should initiate droplet precautions to prevent the transmission of the bacteria to others. These include wearing a surgical mask when within 3 feet of the client, placing the client in a private room or cohorting with another client who has the same infection, and ensuring that visitors wear masks and practice hand hygiene.
D. Protective:
Protective precautions, also known as reverse isolation, are used to protect clients who have compromised immune systems from exposure to pathogens. This precaution is not relevant for a client with pertussis; instead, the focus is on preventing transmission to others through droplet precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Painful urination: Painful urination, also known as dysuria, is not a typical symptom of BPH. Dysuria is more commonly associated with conditions such as urinary tract infections (UTIs) or urethritis rather than BPH.
B) Urge incontinence: While BPH can cause lower urinary tract symptoms such as urgency and frequency, urge incontinence (involuntary loss of urine associated with a sudden urge to urinate) is not typically a primary symptom of BPH. Urge incontinence is more commonly associated with overactive bladder (OAB) syndrome.
C) Critically elevated prostate-specific antigen (PSA) level: While BPH can cause an elevation in PSA levels, a critically elevated PSA level alone is not a definitive diagnostic finding for BPH. PSA levels can be elevated in various conditions affecting the prostate gland, including BPH, prostate cancer, and prostatitis. Therefore, PSA levels must be interpreted in conjunction with other clinical findings and diagnostic tests to accurately assess prostate health and diagnose specific prostate conditions.
D) Difficulty starting the flow of urine: Benign prostatic hyperplasia (BPH) is characterized by the enlargement of the prostate gland, which can obstruct the flow of urine through the urethra. This obstruction leads to symptoms such as difficulty starting the flow of urine, weak urinary stream, urinary hesitancy, and incomplete bladder emptying. These symptoms occur due to the mechanical obstruction of the urethra by the enlarged prostate gland. Difficulty starting the flow of urine is a hallmark symptom of BPH and is often one of the earliest manifestations experienced by affected individuals.
Correct Answer is D
Explanation
A. Light-headedness when standing up:
Elevated potassium levels (hyperkalemia) can lead to muscle weakness or paralysis, cardiac dysrhythmias, and even cardiac arrest. Light-headedness when standing up is more commonly associated with orthostatic hypotension or volume depletion rather than electrolyte imbalances like hyperkalemia.
B. Weak quadriceps muscles:
Weakness in the quadriceps muscles is not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can cause muscle weakness, but it is not specific to the quadriceps.
C. Decreased deep tendon reflexes:
Decreased deep tendon reflexes are not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can lead to hyperreflexia or absent reflexes, but it is not specific to decreased deep tendon reflexes.
D. Tingling of extremities:
This is the correct answer. Hypocalcemia, indicated by the low calcium level in the scenario, can manifest with symptoms such as tingling or numbness of the extremities, muscle cramps, and tetany. Calcium plays a crucial role in nerve transmission, and low levels can lead to sensory disturbances like tingling in the extremities.
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