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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. This position, where the client is seated in a semi-upright sitting position, helps to reduce the risk of aspiration and facilitates breathing. It is also conducive to the proper functioning of the nasogastric tube for decompression.
B. Moistening the client's lips is also important for comfort, but it does not directly relate to the management of the nasogastric tube.
C. Sterile water should be used for irrigation only if the tube becomes clogged.
D. Measuring abdominal girth is important but not specific to nasogastric tube care.

A. Allow the client to expel some fluid before continuing. B. Lower the height of the solution container. C. Encourage the client to bear down. D. Stop the enema and document that the client did not tolerate the procedure.

Correct Answer is B

Explanation

A. Expulsion of water does not address the underlying issue.
B. Lowering the height of the solution container can help reduce the force of the fluid entering the colon, which may lessen cramping. This method slows the flow rate of the solution, allowing the client's body to adjust without stopping the procedure entirely.
C. Bearing down (straining) may increase the discomfort and is not recommended during the administration of an enema. It could potentially lead to rectal trauma or increase intrarectal pressure, which is not beneficial during the procedure.

D. While stopping the procedure is an option if the client is unable to tolerate it due to severe discomfort or distress, in this scenario where cramping is the main issue, allowing the client to expel some fluid is more appropriate before deciding to stop the procedure.

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A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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