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. The oliguric phase of AKI typically lasts longer than 2 days. It can extend from several days to weeks, depending on the underlying cause and the response to treatment.
B. During the oliguric phase of AKI, urine output is significantly reduced. Typically, urine output is less than 400 mL per day, but it can vary widely based on the severity of kidney injury and individual factors.
C. The oliguric phase of AKI usually begins within a few days to a week after the initial injury. It is characterized by a sudden decrease in urine output and may be accompanied by electrolyte imbalances and fluid overload.
D. During the oliguric phase of AKI, there is typically a buildup of waste products such as blood urea nitrogen (BUN) and creatinine in the blood. These levels rise because the kidneys are unable to effectively filter and excrete waste products. Therefore, BUN and creatinine levels usually increase during the oliguric phase.

A. Positioning the client's arm above heart level B. Wrapping the cuff too loosely around the client's arm C. Deflating the cuff too slowly D. Measuring blood pressure right after the client's mealtime

Correct Answer is A

Explanation

A. Positioning the client's arm above heart level can result in a falsely low blood pressure reading. This is because gravity assists in the flow of blood downward, artificially reducing the pressure measured in the arteries. For accurate blood pressure measurement, the client's arm should be positioned at heart level or slightly below heart level.
B. If the blood pressure cuff is wrapped too loosely around the client's arm, it can lead to inaccurate readings. A loose cuff may allow leakage of air during inflation or may not provide sufficient compression to accurately detect the arterial pressure pulses.
C. Deflating the cuff too slowly can cause a falsely high diastolic pressure reading. When the cuff is deflated slowly, the pressure in the cuff remains close to the systolic pressure for a longer duration, leading to incorrect readings, especially in diastolic pressure.
Blood pressure can temporarily increase after meals due to digestion, particularly in clients with hypertension. Measuring blood pressure immediately after a meal may result in a higher reading that does not reflect the client's baseline blood pressure. However, this would typically lead to a higher reading rather than a lower one.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about the oliguric phase of acute kidney injury. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Correct Answer is A

Explanation

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