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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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Correct Answer is C

Explanation

c. The toddler can say four words.

Explanation:

The nurse should report to the provider that the toddler can say four words. At 18 months, a toddler typically has a vocabulary of about 6 to 20 words and is beginning to combine words into simple phrases. If the toddler is only able to say four words or has a delay in language development, it could be a cause for concern and warrant further evaluation.

The other options are age-appropriate developmental milestones for an 18-month-old toddler and do not require immediate reporting to the provider. The ability to remove socks, having a security blanket, and throwing a ball without falling are all examples of normal developmental skills for a toddler of this age.

A. The client's blood pressure has been reduced. B. The client exhibits diaphoresis C. The client is not grimacing D. The client has an elevated heart rate

Correct Answer is C

Explanation

Answer: (C) The client is not grimacing

Rationale:

A) The client's blood pressure has been reduced:

While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.

B) The client exhibits diaphoresis:

Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.

C) The client is not grimacing:

The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.

D) The client has an elevated heart rate:

An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.

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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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