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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Airborne:
Airborne precautions are used for infections transmitted via small droplet nuclei that remain suspended in the air for long periods and can be inhaled by others. Examples of diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. Pertussis is not transmitted via the airborne route.

B. Contact:
Contact precautions are used for infections spread by direct or indirect contact with the client or their environment. Examples include Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Pertussis is primarily spread through respiratory droplets rather than contact with contaminated surfaces.

C. Droplet:
Pertussis is primarily spread through respiratory droplets when an infected person coughs or sneezes. The nurse should initiate droplet precautions to prevent the transmission of the bacteria to others. These include wearing a surgical mask when within 3 feet of the client, placing the client in a private room or cohorting with another client who has the same infection, and ensuring that visitors wear masks and practice hand hygiene.

D. Protective:
Protective precautions, also known as reverse isolation, are used to protect clients who have compromised immune systems from exposure to pathogens. This precaution is not relevant for a client with pertussis; instead, the focus is on preventing transmission to others through droplet precautions.

A. Calcium gluconate 1.5 grams IV now B. Dextrose 50% injection (50ml) IV push now C. Colace 100 mg PO now D. Regular insulin 10 units IV now E. Potassium chloride 20 mEq orally now

Correct Answer is ["A","B","D"]

Explanation

A) Calcium gluconate 1.5 grams IV now: Calcium gluconate is administered to counteract the effects of hyperkalemia by stabilizing the myocardial cell membrane. It does not lower potassium levels but helps protect the heart from potential dysrhythmias associated with high potassium levels.

B) Dextrose 50% injection (50ml) IV push now: Dextrose 50% injection, also known as D50W, is administered to temporarily shift potassium from the extracellular space into the intracellular space, thereby lowering serum potassium levels. It is commonly used in combination with insulin to facilitate the movement of potassium into cells.

C) Colace 100 mg PO now: Colace is a stool softener and does not affect serum potassium levels. It is not indicated for the treatment of hyperkalemia.

D) Regular insulin 10 units IV now: Regular insulin is administered with dextrose to facilitate the movement of potassium from the extracellular space into the intracellular space. Insulin stimulates the cellular uptake of glucose, which in turn drives potassium into cells along with glucose.

E) Potassium chloride 20 mEq orally now: Potassium chloride is contraindicated in the treatment of hyperkalemia as it would further increase serum potassium levels. It is typically used to supplement potassium in clients with hypokalemia, not hyperkalemia.

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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?

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