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. Sublingual nitroglycerin is intended for the immediate relief of angina symptoms. Clients should take the medication as soon as they experience chest pain or discomfort. Prompt administration can help alleviate symptoms and prevent the progression of angina episodes.
A. If the chest pain persists or worsens after taking the first dose of sublingual nitroglycerin, the client can take a second dose after 5 minutes. However, taking another dose after only 2 minutes may increase the risk of hypotension and other adverse effects.
C. Sublingual nitroglycerin tablets are not meant to be chewed or swallowed. Instead, they should be placed under the tongue and allowed to dissolve completely. Chewing or swallowing the tablet can reduce the medication's effectiveness.

D. Sublingual nitroglycerin should be placed under the tongue, not against the cheek or gum.

A. Maintain peripheral IV access. B. Pad the upper two side rails of the client's bed. C. Teach assistive personnel how to apply restraints. D. Keep a padded tongue blade at the client's bedside.

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.

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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

A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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