A nurse is assisting with the admission of a client who has mononucleosis. Which of the following isolation precautions should the nurse initiate?

Airborne

Droplet

Contact

Protective environment

Answer and Explanation

The Correct Answer is C

A. Airborne precautions are used for diseases transmitted by tiny particles that remain suspended in the air and are inhaled, such as tuberculosis or measles. Mononucleosis is not spread through
the airborne route.

B.   Droplet precautions are for diseases transmitted by respiratory droplets, like influenza or pertussis. While mononucleosis can be transmitted through respiratory secretions, it's primarily spread through direct contact with saliva.
C.   Contact precautions involve preventing the transmission of pathogens by direct or indirect contact. Given that mononucleosis is transmitted through saliva, contact precautions, including wearing gloves and gowns, are appropriate to prevent its spread.
D.   Protective environment precautions are used to protect immunocompromised patients from outside pathogens, such as those recovering from bone marrow transplants. They are not applicable for a client with mononucleosis.

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Correct Answer is C

Explanation

A. "You can take your child to stores on weekends." Neutropenic clients are at increased risk of infection, so avoiding crowded places like stores is advisable.
B. "You should inspect your child's mouth weekly for ulcers." Neutropenic clients are at risk of developing oral mucositis, so mouth inspections should be performed daily, not weekly.
C. "You should notify your provider if your child has a fever." Neutropenic clients are at high risk of infection-related complications, and fever can be an early sign of infection. Prompt notification of healthcare providers is essential for timely intervention.
D. "You can give your child fresh fruit for snacks." Neutropenic clients should avoid fresh fruits and vegetables that cannot be peeled or cooked, as they may harbor bacteria that can cause infection.

A. Changing the dressing on a client's IV site B. Suctioning a client's new tracheostomy C. Evaluating a client's risk for developing pressure injuries D. Administering a large-volume enema to a client E. None F. None

Correct Answer is A

Explanation

A. Changing the dressing on a client's IV site: This is a sterile procedure and requires the nurse’s clinical expertise. It cannot be delegated to assistive personnel (AP).

B. Suctioning a client's new tracheostomy: Suctioning a tracheostomy, especially a new one, is a sterile procedure requiring clinical judgment and skill, which is beyond the scope of assistive personnel.

C. Evaluating a client's risk for developing pressure injuries: This is an assessment task that requires clinical judgment and critical thinking. It falls under the nurse’s scope of practice and should not be delegated to AP.

D. Administering a large-volume enema to a client: Assisting with or administering an enema is a task that can be delegated to assistive personnel, as it is within their scope of practice, provided the client is stable and the procedure does not require complex judgment.

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A nurse is assisting with the admission of a client who has mononucleosis. Which of the following isolation precautions should the nurse initiate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

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