A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?
Providing a newborn's first bath
Giving personal care to an infant who is HIV-positive
Suctioning secretions from a child's newly placed tracheostomy tube
Withdrawing cord blood from a neonate
Transporting a cerebrospinal fluid specimen to the laboratory
The Correct Answer is C
Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.
Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.
Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.
Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.
Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.
Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.
Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.
Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.
Correct Answer is D
Explanation
Choice A reason: Protective precautions are used to shield immunocompromised patients from infections, not typically for patients with meningococcal pneumonia.
Choice B reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Meningococcal pneumonia is not primarily spread this way.
Choice C reason: Airborne precautions are for diseases that are spread through the air over long distances, such as tuberculosis. Meningococcal pneumonia is not spread in this manner.
Choice D reason: Droplet precautions are recommended for meningococcal pneumonia. This infection can be spread through droplets from the respiratory tract when the infected person coughs or sneezes. Therefore, droplet precautions, including the use of masks, are necessary to prevent the spread of this infection.
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