A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?
Contact
Airborne
Droplet
Protective
The Correct Answer is D
A) Contact: While contact precautions are important for preventing the transmission of infections, they primarily apply to clients with known or suspected infections that can spread through direct or indirect contact with the client or their environment. Protective isolation goes beyond contact precautions and involves comprehensive measures to protect immunocompromised clients from all potential sources of infection.
B) Airborne: Airborne precautions are necessary for clients with infections that spread through the airborne route, such as tuberculosis or measles. While respiratory infections can pose a significant risk to immunocompromised clients, the focus of care for clients after hematopoietic stem-cell transplant is on preventing all types of infections, not just airborne ones.
C) Droplet: Droplet precautions are used for infections transmitted through respiratory droplets expelled when a person coughs, sneezes, or talks, such as influenza or pertussis. While respiratory infections are a concern for immunocompromised clients, the broader approach of protective isolation is more appropriate for clients after hematopoietic stem-cell transplant, as it encompasses all potential routes of infection transmission, not just droplet spread.
D) Protective: Clients who have undergone allogeneic hematopoietic stem-cell transplant are profoundly immunocompromised due to the destruction of their immune system and are highly susceptible to infections. Protective isolation, also known as reverse isolation, is necessary to minimize the risk of infection in these clients. This includes implementing strict infection control measures such as wearing gowns, gloves, masks, and sometimes goggles to prevent exposure to pathogens. Additionally, maintaining a clean environment and limiting visitors and healthcare personnel who may carry infectious agents are essential components of protective isolation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Placing the soiled linen on the floor before bagging it is unsanitary and violates infection control principles. It increases the risk of spreading pathogens to other surfaces, potentially contaminating the environment.
B. Placing clean linen that touched the floor in the soiled linen bag prevents cross-contamination and maintains cleanliness. It adheres to infection control standards by ensuring that only soiled items are disposed of appropriately.
C. Holding the soiled linen against her body while carrying it to the linen bag risks transferring pathogens to the caregiver's clothing and skin, compromising personal hygiene and promoting contamination.
D. Shaking the soiled linen to remove any toilet paper remnants is ineffective and hazardous. It disperses potentially infectious particles, increasing the risk of contamination and compromising infection control efforts.
Correct Answer is C
Explanation
A) Gelatin: Gelatin is a suitable choice for a clear liquid diet. It is transparent and easily digestible, making it appropriate for individuals requiring clear liquids, such as those recovering from certain medical procedures or surgeries.
B) Popsicle: Popsicles are commonly included in clear liquid diets. They provide hydration and can help soothe a sore throat or provide relief from nausea. However, it is essential to ensure that the popsicle is clear and does not contain any solid fruit or pieces.
C) Yogurt: Yogurt is not typically included in a clear liquid diet. Clear liquid diets consist of transparent or translucent fluids that are easily digested and leave minimal residue in the gastrointestinal tract. Yogurt, being a semi-solid food, contains particles that are not clear and is typically considered a full liquid or soft diet item rather than a clear liquid. Therefore, the client's choice of yogurt indicates a need for further teaching regarding appropriate food choices for a clear liquid diet.
D) Broth: Broth, such as chicken or beef broth, is a staple of clear liquid diets. It is easily digested and provides essential electrolytes and hydration. Broth can be consumed hot or cold, depending on the client's preference and medical condition.
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