A nurse is educating a client who is under protective isolation precautions. Which statement from the client indicates they have understood the teaching?
“I can shower up to three times a week.”.
“I will inform my friends and family to visit when I’m feeling well.”.
“I can take a plane to visit my grandchildren.”.
“I will wear a face mask when leaving my hospital room.”.
The Correct Answer is D
Choice A rationale
While showering frequency can vary depending on the specific isolation precautions, it does not indicate understanding of the protective isolation precautions.
Choice B rationale
Informing friends and family to visit when feeling well does not indicate understanding of protective isolation precautions. Protective isolation precautions are designed to protect the patient from infections, not based on how the patient is feeling.
Choice C rationale
Taking a plane to visit grandchildren does not indicate understanding of protective isolation precautions. Travel restrictions would depend on the specific condition and doctor’s advice.
Choice D rationale
Wearing a face mask when leaving the hospital room is a common requirement in protective isolation precautions to prevent the spread of infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The statement “What did I do to deserve this illness?” could indicate spiritual distress. This statement suggests that the patient may be struggling with feelings of guilt, punishment, or existential crisis, which are common manifestations of spiritual distress. The patient may be
questioning their moral or spiritual worth, or trying to find meaning or purpose in their suffering.
Choice B rationale
The statement “I blame medical science for not finding a cure” could indicate frustration or anger, but it does not necessarily indicate spiritual distress. While this statement suggests dissatisfaction with medical progress, it does not directly relate to the patient’s spiritual or existential concerns.
Choice C rationale
The statement “Where is my daughter when I need her most?” could indicate emotional distress related to the patient’s interpersonal relationships, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel abandoned or unsupported, but it does not directly relate to the patient’s spiritual or existential concerns.
Choice D rationale
The statement “Will I ever regain control over my life?” could indicate emotional distress related to the patient’s sense of autonomy and control, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel helpless or powerless in the face of their illness, but it does not directly relate to the patient’s spiritual or existential concerns.
Correct Answer is C
Explanation
Choice A rationale
Inserting the needle at a 15-degree angle is not recommended for subcutaneous injections like heparin. The needle should be inserted at a 90-degree angle.
Choice B rationale
Aspirating for blood return before administration is not necessary when administering heparin.
Choice C rationale
Heparin should be administered into the abdominal fat layer, above the iliac crest and at least 2 inches away from the umbilicus.
Choice D rationale
Massaging the site after the injection is not recommended as it can cause bruising.
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