A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Monitor the client's temperature once every 6 hr.

Make sure the client's room has positive-pressure airflow.

Wear an N95 respirator when providing direct client care.

Make sure dietary plates and utensils are disposable.

Answer and Explanation

The Correct Answer is C

A. Monitoring of vital signs should be more frequent

B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.

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Correct Answer is B

Explanation

B. Seizures can result in sudden and uncontrollable movements, which may increase the risk of injury if the client strikes against the side rails of the bed during a seizure episode. Padding the upper two side rails helps minimize the risk of injury by providing a softer surface.
A. Maintaining peripheral IV access ensures that these medications can be administered promptly. However, other routes such as rectal can also be used therefore not a priority
C. Assisting personnel should not be trained in the proper application of restraints as it is not within the scope of their practice.
D. Introduction of objects during a seizure is not recommended as it increases the risk of injury.

A. Urinary hesitancy B. Painless vaginal bleeding C. Unexplained weight gain D. Frequent diarrhea

Correct Answer is B

Explanation

B. Painless vaginal bleeding, especially after sexual intercourse or between menstrual periods, can be an early sign of cervical cancer. This bleeding may occur due to cervical lesions or abnormalities, such as cervical dysplasia or cervical cancer. It is important for individuals to report any abnormal vaginal bleeding to their healthcare provider for further evaluation.
A. Urinary hesitancy, which is difficulty starting urination or a delay in the initiation of the urinary stream, is not typically associated with cervical cancer.
C. Unexplained weight gain is not typically associated with cervical cancer.
D. Frequent diarrhea is not typically associated with cervical cancer.

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A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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