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 D

Explanation

A. Indwelling urinary catheters are associated with an increased risk of urinary tract infections (UTIs) and other complications, including skin irritation and breakdown around the catheter site. Routine use of indwelling catheters is not recommended for managing routine urinary incontinence due to these risks.

B. Using hot water or harsh cleansers can strip the skin of its natural oils and lead to further irritation and breakdown. Instead, gentle cleansing with mild soap and warm water is recommended after each episode of incontinence to remove urine and prevent skin irritation. Patting the skin dry rather than rubbing can also help prevent damage to the skin barrier.
C. Regular skin assessment is crucial in clients with urinary incontinence to identify early signs of skin breakdown. Checking the skin every 8 hours may not be frequent enough, particularly if the client is incontinent frequently. More frequent assessment, ideally after each episode of incontinence or at least every 2-4 hours, is recommended to promptly identify and address any skin issues.
D. Applying a moisture barrier ointment or cream to the perineal area and any areas prone to moisture can help protect the skin from urine and fecal exposure. These products create a barrier that prevents direct contact of urine with the skin, reducing the risk of irritation and breakdown. Regular application, especially after cleansing and as needed throughout the day, can help maintain skin integrity.

A. A client who has end-stage kidney disease who will undergo dialysis B. A client who has gastroenteritis and is receiving oral fluids C. A client who has heart failure and is receiving diuretic therapy D. A client who has NPO status since midnight for an endoscopy

Correct Answer is B

Explanation

A. Clients with end-stage kidney disease often have impaired kidney function, leading to decreased urine output and retention of fluid and waste products. Dialysis is intended to remove excess fluid and waste from the body.
B. Gastroenteritis involves inflammation of the gastrointestinal tract, leading to symptoms such as diarrhea and vomiting. These symptoms result in significant fluid loss.
C. Heart failure can lead to fluid retention and edema due to the heart's inability to pump effectively. Diuretic therapy is commonly prescribed to manage fluid overload by increasing urine output. However, excessive diuresis or inadequate intake of fluids can lead to fluid volume deficit, particularly if the client does not compensate with adequate oral intake.

D. This client has been NPO only since midnight (about 9–14 hours, depending on procedure time). While intake is restricted, this short period is not usually enough to cause a significant fluid volume deficit, unless prolonged.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?

Correct Answer is D

Explanation

A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Correct Answer is B

Explanation

A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding?

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