A nurse is assisting with planning care for a client who was admitted for reports of severe coughing, night sweats, and blood in the sputum. Which of the following precautions should the nurse take?
Place the client in a negative-pressure airflow room.
Wear a surgical mask when entering the client's room.
Have a container for soiled linens outside the client's door.
Remain within 91.4 cm (3 ft) of the client.
The Correct Answer is A
A. Place the client in a negative-pressure airflow room: This is correct as these symptoms are indicative of tuberculosis (TB), which requires airborne precautions. A negative-pressure room helps to prevent the spread of airborne pathogens.
B. Wear a surgical mask when entering the client's room: This is incorrect because a surgical mask does not provide adequate protection against airborne particles; an N95 respirator is necessary for airborne precautions.
C. Have a container for soiled linens outside the client's door: This is incorrect as soiled linens should be handled and disposed of within the room under appropriate infection control protocols, not just placed outside.
D. Remain within 91.4 cm (3 ft) of the client: This is incorrect as maintaining this distance does not prevent the spread of airborne diseases. Proper airborne precautions, including the use of personal protective equipment, are necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Leaning forward: This is correct as the client should be in a sitting position with arms resting on a table or a support to allow the lungs to expand and make the pleural space more accessible for the procedure.
B. Prone: This is incorrect because the prone position would not provide the necessary access to the pleural space and would be uncomfortable for the procedure.
C. Lithotomy: This is incorrect as the lithotomy position is used for gynecological procedures, not for thoracentesis.
D. Knees elevated: This is incorrect because elevating the knees is not a suitable position for thoracentesis and does not facilitate access to the pleural space.
Correct Answer is B
Explanation
A. Apply a heat pack to the client's lower abdomen: This is incorrect as applying heat can worsen inflammation and increase the risk of rupture; ice packs are generally used instead.
B. Place the client in semi-Fowler's position: This is correct as the semi-Fowler's position helps reduce pain and pressure on the abdomen and can improve comfort before surgery.
C. Give the client a clear liquid diet: This is incorrect as a clear liquid diet is not appropriate for a client with acute appendicitis who may require NPO (nothing by mouth) status prior to surgery.
D. Administer an enema to the client: This is incorrect as enemas are contraindicated in acute appendicitis due to the risk of perforation and worsening of the condition.
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