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","C","F","H"]

Explanation

The client has diabetes ketoacidosis (DKA) as seen in the lab findings. The management of DKA involves fluid rehydration with isotonic crystalloids such as normal saline, glycemic control with intravenous insulin infusion and electrolyte supplementation specifically potassium if it is normal or low.

This is because administration of insulin drives potassium ions into the cells leading to hypokalemia Cardiac monitoring is vital to ensure that any dysrhythmias due to electrolyte disturbances are recognized early.

Blood sugar monitoring should be done more frequently- preferably every 1 hour. Although monitoring of output is key, catheterization is unnecessary when the client is awake.

A. Place the client in a supine position. B. Administer antihypertensive medications. C. Monitor the client for hypercalcemia. D. Maintain the client on NPO status.

Correct Answer is D

Explanation

D. NPO status is typically implemented in the initial management of acute pancreatitis to rest the pancreas and reduce pancreatic enzyme secretion, which can exacerbate inflammation and tissue damage. Nutritional support may be gradually reintroduced once the client's condition stabilizes and symptoms improve.
A. Placing the client in a supine position is not recommended for acute pancreatitis because it can exacerbate pain and discomfort.
B. The priority in acute pancreatitis is to address pain, manage complications such as fluid imbalances or infections, and support pancreatic rest.

C. Hypercalcemia can occur as a complication of acute pancreatitis due to calcium mobilization from damaged pancreatic cells. However, keeping the client NPO is priority.

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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 caring for a client in the emergency department. Exhibits Which of the following 3 provider prescriptions does the nurse anticipate?

Correct Answer is ["B","C","F","H"]

Explanation

A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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