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. "I would like to see what this looks like today": This indicates effective coping as the client is engaging with their condition and facing the changes directly, which is an important step in emotional adjustment and recovery.
B. "I'm going to close my eyes until you are done dressing my incision": This suggests avoidance of the situation, which may indicate difficulty in coping with the reality of their condition.
C. "I would just like to spend my day staring at the TV": This may indicate withdrawal or avoidance, which is not an effective coping strategy.
D. "I'm planning to stay at home until my breast reconstructive surgery": While this may be part of the client's plan, it does not directly indicate effective coping with the current situation.
Correct Answer is D
Explanation
A. "You may drink full liquids until 6 hours before the procedure": Typically, clients are instructed to follow a clear liquid diet and to stop drinking any liquids a few hours before the procedure, not full liquids.
B. "You will lie on your right side for the procedure": The client usually lies on their left side during a colonoscopy, not the right side.
C. "You should warm the liquid bowel preparation before drinking it": Bowel preparation solutions are generally not warmed; they are consumed as directed, often chilled to make them more palatable.
D. "You will be moderately sedated during the procedure": This is correct as colonoscopy usually involves moderate sedation to ensure client comfort and tolerance during the procedure.
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