A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?

Wear gloves when entering the client's room.

Encourage the client to ambulate in the hall.

Wear an N95 respirator mask.

Provide a positive pressure airflow room.

Answer and Explanation

The Correct Answer is C

A.   Gloves are not specifically required for airborne precautions unless contact with infectious secretions or materials is anticipated. Airborne precautions primarily focus on preventing inhalation of infectious droplet nuclei. Therefore, wearing gloves is not necessary solely due to airborne precautions.
B.   This option is not related to airborne precautions. Encouraging ambulation in the hall is a general nursing intervention and does not specifically address preventing the transmission of airborne pathogens.
C.   An N95 respirator mask is designed to filter out 95% of airborne particles, including those containing infectious agents. It provides respiratory protection for healthcare workers who may be exposed to airborne pathogens during procedures such as aerosol-generating procedures (e.g., suctioning, bronchoscopy) or when caring for clients with airborne infections.
D.   Positive pressure airflow rooms are typically used for clients requiring protective isolation (e.g., immunocompromised clients) but are not specifically required for clients on airborne precautions. Negative pressure airflow rooms are preferred for clients on airborne precautions because they prevent the spread of airborne pathogens to other areas of the facility.

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Correct Answer is B

Explanation

A. This option involves informing the healthcare provider about the lack of urinary output. This is important because it could indicate an obstruction or clot formation in the urinary catheter or drainage system, which may require immediate intervention.
B. Checking the patency of the urinary catheter tubing is crucial. The nurse should assess for any kinks, twists, or clots that may be obstructing urine flow. Flushing the catheter per protocol or irrigating it with sterile saline may help clear any obstruction.
C. Increasing oral fluids may help promote urine production once any obstruction or issue with the catheter is resolved. However, this action should come after addressing the immediate concern of no urinary output and ensuring the catheter's patency.
D. While pain management is important postoperatively, administering an analgesic is not the priority in this scenario where there is no urinary output. Pain from the procedure is typically managed with medications prescribed on a schedule or as needed, but it does not address the acute issue of urinary obstruction.

A. A deep crater without visible bone, tendon, or muscle B. Unbroken skin with un-blancheable erythema C. A shallow, ruptured or intact skin blister without slough D. Full-thickness tissue loss extending to underlying support structures

Correct Answer is A

Explanation

A. A stage 3 pressure ulcer is characterized by full-thickness skin loss that may extend into the subcutaneous tissue layer but does not involve exposure of muscle, tendon, or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue as well.
B. This describes a stage 1 pressure ulcer. Stage 1 ulcers involve intact skin with non-blanchable redness, indicating potential damage to underlying tissue.

C. This describes a stage 2 pressure ulcer. Stage 2 ulcers involve partial-thickness loss of skin involving the epidermis and/or dermis, presenting as a shallow open ulcer or intact blister.
D. Accurately describes a stage 4 pressure ulcer.

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A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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