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. Positioning the client's arm above heart level can result in a falsely low blood pressure reading. This is because gravity assists in the flow of blood downward, artificially reducing the pressure measured in the arteries. For accurate blood pressure measurement, the client's arm should be positioned at heart level or slightly below heart level.
B. If the blood pressure cuff is wrapped too loosely around the client's arm, it can lead to inaccurate readings. A loose cuff may allow leakage of air during inflation or may not provide sufficient compression to accurately detect the arterial pressure pulses.
C. Deflating the cuff too slowly can cause a falsely high diastolic pressure reading. When the cuff is deflated slowly, the pressure in the cuff remains close to the systolic pressure for a longer duration, leading to incorrect readings, especially in diastolic pressure.
Blood pressure can temporarily increase after meals due to digestion, particularly in clients with hypertension. Measuring blood pressure immediately after a meal may result in a higher reading that does not reflect the client's baseline blood pressure. However, this would typically lead to a higher reading rather than a lower one.

A. Wear gloves when entering the client's room. B. Encourage the client to ambulate in the hall. C. Wear an N95 respirator mask. D. Provide a positive pressure airflow room.

Correct Answer is C

Explanation

A. Gloves are not specifically required for airborne precautions unless contact with infectious secretions or materials is anticipated. Airborne precautions primarily focus on preventing inhalation of infectious droplet nuclei. Therefore, wearing gloves is not necessary solely due to airborne precautions.
B. This option is not related to airborne precautions. Encouraging ambulation in the hall is a general nursing intervention and does not specifically address preventing the transmission of airborne pathogens.
C. An N95 respirator mask is designed to filter out 95% of airborne particles, including those containing infectious agents. It provides respiratory protection for healthcare workers who may be exposed to airborne pathogens during procedures such as aerosol-generating procedures (e.g., suctioning, bronchoscopy) or when caring for clients with airborne infections.
D. Positive pressure airflow rooms are typically used for clients requiring protective isolation (e.g., immunocompromised clients) but are not specifically required for clients on airborne precautions. Negative pressure airflow rooms are preferred for clients on airborne precautions because they prevent the spread of airborne pathogens to other areas of the facility.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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