A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?
Wear a mask when entering the client's room.
Dedicate equipment and supplies for use with the client.
Allow the client to leave the room every 2 hr.
Remove potted plants from the room.
The Correct Answer is B
A. Contact precautions primarily focus on preventing direct transmission of pathogens through physical contact. Therefore, wearing a mask is not typically required unless the client is also suspected or known to have respiratory infections that require airborne precautions. The standard precautions include wearing gloves and a gown when entering the client's room.
B. This is a key principle of contact precautions. The nurse should ensure that equipment (such as blood pressure cuffs, stethoscopes) and supplies (like thermometers) used for the client are dedicated solely to that client and are not shared with other clients. This helps prevent the spread of pathogens to other clients or areas of the healthcare facility.
C. Contact precautions involve limiting the client's movement outside of their room to essential purposes only. Allowing the client to leave the room frequently increases the risk of spreading infectious agents to other areas of the healthcare facility and to other individuals.
D. Potted plants can harbor soil that may contain microorganisms. Contact precautions focus on preventing direct transmission through physical contact, and while soil is not typically a medium for transmission of common healthcare-associated pathogens, removing plants helps maintain cleanliness and reduces potential reservoirs for contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Atrial fibrillation is characterized by an irregularly irregular pulse. This means that the rhythm of the pulse lacks a discernible pattern; it may be irregularly fast or slow, with varying intervals between beats. Therefore, "irregular" is an appropriate term to describe the quality of the pulse in a client with atrial fibrillation.
B. While some clients with atrial fibrillation may have a slow heart rate (bradycardia), not all do. Atrial fibrillation itself typically presents with an irregular rhythm rather than a consistently slow pulse rate. Thus, "slow" may not accurately describe the quality of the pulse in atrial fibrillation.
C. "Not palpable" refers to the inability to feel or detect a pulse. In atrial fibrillation, the pulse is usually palpable but irregular. Therefore, "not palpable" would not be an accurate term to describe the pulse quality in this condition.
D. "Bounding" describes a pulse that is strong and forceful. In atrial fibrillation, the pulse may vary in strength and typically does not have a bounding quality. This term would not accurately describe the pulse quality in a client with atrial fibrillation.
Correct Answer is ["B","D","E"]
Explanation
A. Lactose intolerance does not directly increase the risk of aspiration. It is a condition where the body cannot easily digest lactose, a type of sugar found in dairy products, leading to gastrointestinal symptoms such as bloating, diarrhea, and gas. Aspiration risk is not typically associated with lactose intolerance.
B. Clients who have had a stroke often experience dysphagia (difficulty swallowing) due to impaired coordination of the muscles involved in swallowing. This dysphagia can lead to food or liquids entering the airway instead of the esophagus, increasing the risk of aspiration.
C. Prolonged diarrhea does not directly increase the risk of aspiration during eating. Diarrhea is a gastrointestinal symptom that typically affects the lower digestive tract and is not directly related to swallowing or aspiration risk.
D. After surgery, especially under general anesthesia, clients may have impaired protective airway reflexes and reduced consciousness level, increasing the risk of aspiration. The recovery phase postoperatively is critical, as clients may not have regained full control of their swallowing reflexes.
E. Radiation therapy in the head and neck region can cause tissue damage, including to the muscles and nerves involved in swallowing. This damage can result in dysphagia and increase the risk of aspiration during eating.
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