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A nurse is caring for a client who has been placed on contact isolation precautions. Which of the following interventions should the nurse implement?

Inform visitors to remain at least 3 feet away from the client.

Apply sterile gloves when entering the client's room.

Leave all equipment that is used routinely in the client's room

Place the client in a negative-pressure airﬂow room

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale:

While maintaining a distance of 3 feet can reduce the risk of direct contact transmission, it is not the most effective measure for contact isolation precautions.
Contact isolation aims to prevent the spread of pathogens that can be transmitted through direct or indirect contact with the infected person or contaminated objects.
A distance of 3 feet may not be sufficient to prevent transmission via droplets or fomites (inanimate objects that can harbor infectious agents).

Choice B rationale:

Sterile gloves are not routinely required for contact isolation precautions.
They are primarily used for sterile procedures or when there is a risk of exposure to blood or body fluids.
For contact isolation, standard clean gloves are usually sufficient to protect against transmission via direct contact.

Choice C rationale:

Leaving equipment that is used routinely in the client's room is a crucial part of contact isolation precautions.
This practice prevents the spread of infection by minimizing the movement of potentially contaminated items outside of the isolation room.
Equipment like stethoscopes, blood pressure cuffs, and thermometers should be dedicated to the client's use and not shared with other patients.

Choice D rationale:

Negative-pressure airflow rooms are used for airborne isolation precautions, which are designed to prevent the spread of pathogens that can be transmitted through the air.
Contact isolation does not specifically require a negative-pressure room, as the primary mode of transmission is through direct or indirect contact, not airborne particles.

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Related Questions

A. Constipation: Constipation is not a common or significant side effect of cefazolin. While antibiotics can sometimes cause gastrointestinal disturbances such as diarrhea or nausea, constipation is unlikely to be a major concern for this medication. The adolescent should be encouraged to maintain hydration and a balanced diet, but constipation is not a priority symptom to report in this case. B. Elevated skin patches: Elevated skin patches or rashes could be a sign of an allergic reaction to cefazolin, but this is not the most immediate or critical symptom to monitor for in the context of the question. If an allergic rash develops, the adolescent should certainly report it, but elevated skin patches are more general and not directly associated with a serious or common side effect of cefazolin. Immediate concerns would be other signs of an allergic reaction, such as swelling or difficulty breathing. C. Ringing in the ears: Ringing in the ears (tinnitus) can be a sign of ototoxicity, a known side effect of cefazolin, especially when administered in high doses or for prolonged periods. Ototoxicity can affect hearing and balance, and tinnitus is an early symptom. This is a serious issue that should be reported immediately, as the drug might need to be adjusted or discontinued to prevent permanent damage to the ears. D. Depression: While depression is a serious condition that can affect adolescents, it is not a known side effect of cefazolin. If an adolescent experiences mood changes or symptoms of depression, these should be addressed, but they are unlikely to be directly related to the medication. Depression should always be taken seriously and managed, but it is not a primary concern related to cefazolin use.

Correct Answer is C

Explanation

c. Ringing in the ears.

Explanation:

Cefazolin is an antibiotic medication that belongs to the class of cephalosporins. While it is generally safe and well-tolerated, it can have potential side eﬀects that should be monitored and reported to the healthcare provider. One of the potential side eﬀects of cefazolin is ototoxicity, which can manifest as ringing in the ears (tinnitus) or other hearing disturbances. If the adolescent experiences any ringing in the ears or changes in hearing while taking cefazolin, it should be reported to the healthcare provider for further evaluation.

Options a, b, and d are not specifically associated with the use of cefazolin. Constipation can occur due to various reasons unrelated to this medication. Elevated skin patches may be indicative of an allergic reaction or other skin condition but are not specific to cefazolin. Depression is not a common side eﬀect of cefazolin and should be evaluated separately if experienced by the adolescent.

A. Restrict the client's ﬂuid intake B. Keep suction equipment at the client's bedside C. Instruct the client to look down when ambulating D. Position the client supine after eating

Correct Answer is B

Explanation

b. Keep suction equipment at the client's bedside.

The nurse should plan to include keeping suction equipment at the client's bedside as an intervention for a client with Parkinson's disease. Parkinson's disease can cause dysphagia (difficulty swallowing) and an increased risk of aspiration. Having suction equipment readily available allows for prompt intervention in case of choking or aspiration episodes, ensuring the client's safety.

Explanation for the other options:

a. Restrict the client's ﬂuid intake: Restricting the client's ﬂuid intake is not typically indicated in the care of a client with Parkinson's disease. Adequate hydration is important for overall health and well-being. However, specific ﬂuid restrictions may be necessary in certain situations, such as if the client has coexisting conditions like heart failure or kidney disease, which should be assessed and determined by the healthcare provider.

c. Instruct the client to look down when ambulating: In Parkinson's disease, individuals often experience a forward-ﬂexed posture and a shuﬄing gait. Instructing the client to look down when ambulating is not an appropriate intervention. Instead, the nurse should encourage the client to maintain an upright posture, take smaller steps, and focus on taking deliberate and controlled movements to promote stability and reduce the risk of falls.

d. Position the client supine after eating: Positioning the client supine after eating is not recommended for a client with Parkinson's disease. This position can increase the risk of aspiration, as it may promote reﬂux and regurgitation of stomach contents. Instead, the nurse should advise the client to maintain an upright position, such as sitting in a chair or using a recliner with appropriate head support, to aid digestion and reduce the risk of aspiration.

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A nurse is caring for a client who has been placed on contact isolation precautions. Which of the following interventions should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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