A nurse is caring for a client with measles. Which isolation precautions should the nurse implement?
Contact
Standard
Droplet
Airborne
The Correct Answer is D
A. Contact: Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment, such as MRSA or C. difficile. Measles is not primarily spread through direct contact, so contact precautions alone are insufficient.
B. Standard: Standard precautions apply to all clients to prevent transmission of bloodborne and body fluid pathogens. While essential, standard precautions alone do not prevent airborne spread of highly contagious respiratory viruses like measles.
C. Droplet: Droplet precautions are used for pathogens transmitted via large respiratory droplets, such as influenza or pertussis. Measles virus is smaller than droplet size and can remain suspended in the air, so droplet precautions alone do not provide adequate protection.
D. Airborne: Measles is highly contagious via airborne transmission. Airborne precautions, including placement in a negative-pressure room and use of an N95 respirator by healthcare personnel, prevent inhalation of aerosolized virus particles. This is the required precaution for measles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Sudden decrease in consciousness: An acute change in mental status may indicate hypoxia, infection, neurological injury, or other life-threatening conditions. Prompt evaluation and intervention are required.
B. Temperature of 102.1 F (38.9 C): Fever indicates a possible infection or inflammatory process, which requires further assessment and monitoring. High temperature may signal systemic involvement.
C. Pulse oximetry of 88% on room air: Oxygen saturation below 90% reflects hypoxemia and impaired gas exchange. This is an immediate concern and may require supplemental oxygen or urgent intervention.
D. Blood pressure 114/66 mmHg: This blood pressure reading is within normal limits for most adults and does not indicate immediate concern.
E. Respiratory rate of 12 per minute: A respiratory rate of 12 breaths per minute is within the normal adult range (12–20) and does not suggest respiratory compromise.
Correct Answer is B
Explanation
A. The student nurse performs hand hygiene before opening the sterile kit: Performing hand hygiene is a standard infection prevention measure and is appropriate before handling sterile equipment. It maintains asepsis and does not compromise the sterile field.
B. The student nurse uses their sterile hand to reposition the client's leg: Touching the client with a sterile hand contaminates it and breaches the sterile field. Any contact with nonsterile surfaces requires the sterile hand to be re-gloved and sterile equipment to be replaced to maintain asepsis.
C. The student nurse assesses the client for a latex allergy before beginning the procedure: Screening for latex allergy is appropriate and prevents allergic reactions. This step does not compromise sterility and is a proper safety measure.
D. The student nurse instructs the client not to touch the sterile field during the procedure: Educating the client to avoid the sterile field helps maintain asepsis and is a correct infection control practice. It does not necessitate halting the procedure.
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