A nurse is caring for an immunocompromised client on chemotherapy. The family would like to visit. What teaching should the nurse provide to the family regarding protective isolation?
Visitors may bring a fruit basket to increase client's nutrition.
Visitors should be taught to refrain from bringing flowers.
A sick family member can visit as long as they wear a surgical mask.
All visitors must complete hand washing and wear an N95 mask.
The Correct Answer is B
A reason:
Visitors may bring a fruit basket is incorrect. Fresh fruit can carry bacteria and should be avoided.
B reason:
Refraining from bringing flowers is correct. Flowers can carry bacteria and fungi, posing a risk to immunocompromised clients.
C reason:
A sick family member visiting, even with a mask, is incorrect. Sick visitors should avoid contact with immunocompromised clients to prevent infection.
D reason:
All visitors must complete hand washing, but wearing an N95 mask is not necessary unless specifically required. Standard masks are typically sufficient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A reason:
Massaging the skin over bony prominences is incorrect. This can cause damage to underlying tissues, particularly in areas at high risk for pressure ulcers.
B reason:
Using a transfer device to lift the client up in bed is correct. This helps to reduce friction and shear, which can contribute to skin breakdown and pressure ulcer development.
C reason:
Elevating the head of the bed no more than 45 degrees can help, but it is not as directly related to maintaining skin integrity as using a transfer device. Elevating the head too much can increase pressure on the sacrum and heels.
D reason:
Applying cornstarch is not recommended as it can promote fungal growth and irritation. Proper moisture management with barrier creams is more effective for keeping skin dry and intact.
Correct Answer is B
Explanation
A reason:
Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to the bed frame, not the side rail, to ensure the client’s safety and prevent injury in case the side rail is moved.
B reason:
Using a quick-release tie is correct. This allows the restraints to be removed quickly in an emergency, ensuring the client's safety and enabling prompt response to any changes in their condition.
C reason:
Ensuring four fingers fit under the restraints is incorrect. The appropriate fit is typically two fingers to ensure the restraint is not too tight, which could restrict circulation, nor too loose, which could reduce its effectiveness.
D reason:
Anticipating removing the restraints every 4 hours is incorrect. Restraints should be checked more frequently, generally every 1-2 hours, to assess the client's circulation, skin integrity, and need for continued restraint.
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