A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?
A client who has pneumonia.
A client who has measles.
A client who has pertussis.
A client who has methicillin-resistant Staphylococcus aureus (MRSA).
The Correct Answer is B
The correct answer is choice B: A client who has measles.
Choice A rationale:
Airborne precautions are indicated for diseases that spread via small particles suspended in the air, such as droplets or dust particles that remain in the air for prolonged periods. Pneumonia is primarily spread through larger respiratory droplets and is not considered an airborne disease. Therefore, airborne precautions are not necessary for a client with pneumonia.
Choice B rationale:
Measles is a highly contagious airborne disease caused by the measles virus. It is transmitted through respiratory droplets and can remain in the air for an extended period. Initiating airborne precautions, such as wearing an N95 respirator mask and placing the client in a negative pressure isolation room, is crucial to prevent the spread of measles to healthcare workers and other patients.
Choice C rationale:
Pertussis (whooping cough) is primarily spread through respiratory droplets, similar to pneumonia. While it is a serious bacterial infection, it is not classified as an airborne disease. Thus, airborne precautions are not required for a client with pertussis.
Choice D rationale:
Methicillin-resistant Staphylococcus aureus (MRSA) is mainly spread through direct contact with contaminated surfaces or individuals. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air. Standard precautions, including wearing gloves and gowns, are typically sufficient when caring for a client with MRSA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”
Choice A rationale:
Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.
Choice B rationale:
Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.
Choice C rationale:
Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.
Choice D rationale:
Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.
Correct Answer is D
Explanation
The correct answer is choice **d. Providing client information to another nurse at change of shift**.
Choice A rationale:
Sharing the client's prognosis with a family member without the client's consent violates the client's right to confidentiality. The nurse should only disclose information to family members if the client has provided permission or if it is necessary for the client's care.
Choice B rationale:
Discussing the client's status with a member of the spiritual support team may be appropriate if the client has consented to spiritual support and the nurse limits the discussion to information relevant to the spiritual care. However, disclosing the client's diagnosis or other sensitive information without the client's consent would still be a breach of confidentiality.
Choice C rationale:
Collaborating with a nurse from another unit about the client's care is appropriate if it is necessary for the client's treatment and if the discussion is limited to information relevant to the client's care. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.
Choice D rationale:
Providing client information to another nurse at change of shift is necessary for the continuity of the client's care and is considered an appropriate disclosure within the healthcare team. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.
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