A nurse is caring for a client on a medical-surgical unit.

Which of the following actions are part of the isolation precautions for this client?

Place the client in a room with positive airflow.

Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room.

When removing personal protective equipment, remove the gown first.

Provide a mask for the client when they are outside their room.

Don a gown when entering the client's room.

Answer and Explanation

Correct Answer : A,D,E

A. Place the client in a room with positive air flow: Placing the client in a room with positive air flow helps prevent the spread of infectious agents within the healthcare facility. This is particularly important for clients with airborne infections.

D. Provide a mask for the client when they are outside their room: Providing a mask for the client when they are outside their room helps prevent the spread of infectious agents to others if the client has a contagious respiratory infection.

E. Don a gown when entering the client's room: Wearing a gown upon entering the client's room helps protect the nurse from contact with the client's body fluids and reduces the risk of transmitting pathogens to other clients or healthcare workers.

B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room: Hand sanitizer is not a substitute for proper handwashing with soap and water. Hand sanitizer may be used in addition to handwashing, but it is not used with such a specific quantity.

C. When removing personal protective equipment, remove gloves first: When removing personal protective equipment, the correct sequence is to remove gloves, perform hand hygiene, and then remove other items such as gown, mask, and eyewear. This helps prevent contamination of the hands during the process.

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Correct Answer is C

Explanation

Choice A reason:
Protective precautions are not necessary because they (also known as reverse isolation) are used for immunocompromised clients to protect them from potential pathogens carried by healthcare workers or visitors.
Choice B reason:
Droplet precautions are not necessary because they are used for infections spread through larger respiratory droplets, like influenza or pertussis.
Choice C reason:
Airborne precautions should be implemented by the nurse. Tuberculosis (TB) is primarily transmitted through the airborne route, as the bacteria that cause TB can be suspended in the air as tiny particles (droplet nuclei) when an infected person coughs, sneezes, speaks, or sings. These particles can be inhaled by others, leading to the potential transmission of the disease.
Choice D reason:
Contact precautions are not necessary because they are used for infections that are transmitted through direct contact with the client or contaminated surfaces, such as MRSA (Methicillin-resistant Staphylococcus aureus) or C. difficile.

A. Shakiness B. Cool skin C. Thirst D. Confusion

Correct Answer is C

Explanation

A. Shakiness (tremors) is more commonly associated with hypoglycemia, where blood glucose levels drop too low. It is not typically a symptom of hyperglycemia. B. Cool skin is not a typical symptom of hyperglycemia. It is more commonly associated with poor peripheral circulation, which can occur in diabetes but is not specific to hyperglycemia itself. C. Thirst (polydipsia) is a common symptom of hyperglycemia in clients with diabetes mellitus. When blood glucose levels are elevated, the kidneys work to eliminate the excess glucose through urine, leading to increased urine production (polyuria). This increased urine production can result in dehydration, triggering the sensation of thirst as the body tries to maintain fluid balance. Thirst is a more common early indicator. D. Confusion can occur in severe cases of both hyperglycemia (diabetic ketoacidosis) and hypoglycemia. However, it is not specific enough on its own to indicate hyperglycemia without other symptoms like thirst and polyuria.

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A nurse is caring for a client on a medical-surgical unit.

Which of the following actions are part of the isolation precautions for this client?