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 B
Explanation
A) "The health care proxy does not go into effect until I am incapable of making decisions.": This statement is accurate. A health care proxy, also known as a durable power of attorney for health care or health care agent, is appointed to make medical decisions on behalf of the client if they become unable to do so themselves. This can include decisions related to treatment options, end-of-life care, and other medical interventions.
B) "I have to choose a family member as my health proxy.": This statement is incorrect. While some individuals may choose a family member as their health care proxy, it is not a requirement. The client can choose any competent adult who is willing to serve as their health care proxy, including a friend, relative, or even a legal representative.
C) "If I become incapacitated, end-of-life choices will be made by my proxy.": This statement is accurate. The health care proxy is responsible for making medical decisions on behalf of the client if they are unable to do so, including decisions related to end-of-life care and treatment preferences.
D) "I can change who I designate as my health care proxy at any time.": This statement is accurate. The client has the right to change their health care proxy at any time by completing a new advance directive document and revoking any previous designations. It is essential for the client to review and update their advance directives regularly to ensure they reflect their current wishes and preferences.
Correct Answer is B
Explanation
A) The client tolerates a second dose of medication with no greater than 1 peripheral edema:
This does not directly indicate a therapeutic response to epinephrine for angioedema. Angioedema primarily involves swelling of deeper layers of the skin, often around the eyes and lips, and sometimes the throat, which can cause breathing difficulties. Tolerating a second dose of medication with minimal peripheral edema does not specifically address the acute respiratory effects of angioedema.
B) Respirations are unlabored:
This is the correct answer. Angioedema can cause swelling in the airways, leading to difficulty breathing. Epinephrine is used to reduce this swelling and improve airway patency. Unlabored respirations indicate that the airway is not obstructed, which means the epinephrine has successfully alleviated the swelling causing the angioedema.
C) Client reports decreased groin pain of 3 on a 1 to 10 scale:
Decreased groin pain is not relevant to the treatment of angioedema with epinephrine. Pain relief in the groin area does not indicate a therapeutic response to epinephrine, which is primarily used to address airway and anaphylactic symptoms.
D) The client's blood pressure when arising from resting position is at premedication levels:
While epinephrine can affect blood pressure, the main concern with angioedema is airway obstruction rather than blood pressure control. Normalizing blood pressure does not specifically indicate that the epinephrine has successfully treated the angioedema and improved the client's respiratory status.
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