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 C

Explanation

A. The toe could also be affected by the edema leading to inaccurate reading.
B. Placing the pulse oximeter probe on a skin fold is not recommended. Skin folds can obscure proper positioning of the probe and interfere with accurate readings. Additionally, skin folds may not adequately represent blood flow and oxygenation levels compared to other sites.
C. This location is recommended because it is usually free of the issues that can affect the extremities, such as poor circulation or changes in peripheral perfusion, and can provide a more reliable saturation reading.
D. The finger is the most common site for applying a pulse oximeter probe due to its accessibility and reliability. However, in cases where the fingers are not suitable, such as when there is significant edema or thickened toenails, alternative sites like the toe may be preferred.

A. "Go to the emergency room and your provider will meet you there." B. "What else have you been eating?" C. "Come to the office and we will check things out." D. "This is expected because of the way iron is broken down during digestion."

Correct Answer is D

Explanation

A. There is no indication of an emergency based on black stools alone without other concerning symptoms such as severe abdominal pain, cramping, or signs of gastrointestinal bleeding.
B. While gathering more information about the client's diet may be helpful in some cases, it does not address the specific concern about the black stools related to iron supplementation.
C. Unless there are other concerning symptoms, such as gastrointestinal bleeding or significant discomfort, this situation does not typically warrant an immediate visit to the office. It can be managed with reassurance and education over the phone.
D. Iron supplements commonly cause stools to turn black due to the way iron is metabolized in the digestive system. This change in stool color is known as "iron-induced blackening." It occurs because iron supplements contain iron salts that undergo chemical reactions in the gastrointestinal tract, resulting in the production of iron sulfide compounds that impart a black color to the stool.

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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

A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

Correct Answer is C

Explanation

A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

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