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 A

Explanation

Referred pain occurs when pain is felt in an area distant from the actual source of the pain. In pancreatitis, irritation of the diaphragm or phrenic nerve can cause pain to be referred to the left shoulder due to shared nerve pathways.

A. The client asks for help before ambulating. B. The client has a history of urinary incontinence. C. The client lives with their caregiver. D. The client has bronchitis.

Correct Answer is B

Explanation

B. Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
A. This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
C. While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. Bronchitis itself does not directly contribute to an increased fall risk.

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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 assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

Correct Answer is A

Explanation

A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

Correct Answer is B

Explanation

A nurse is reviewing the health history of a client who is scheduled for exploratory surgery. Which of the following food allergies indicates a risk for an allergic reaction to latex?

A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?

A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?

A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?

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?

A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?