A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client's room has at least six air exchanges per hour.

Make sure the client wears a mask when outside their room if there is construction in the area.

Place the client in a private room with negative-pressure airflow.

Wear an N95 respirator when giving the client direct care.

Answer and Explanation

The Correct Answer is B

A. Make sure the client's room has at least six air exchanges per hour: Protective environment rooms for stem cell transplant clients require positive-pressure airflow with HEPA filtration, not just a minimum number of air exchanges. Simply having six air exchanges per hour may not adequately prevent airborne pathogens from entering the room.

B. Make sure the client wears a mask when outside their room if there is construction in the area: Clients with severe immunosuppression, such as those who have had an allogeneic stem cell transplant, are highly susceptible to airborne fungal spores, especially during construction or renovation. Wearing a mask when leaving the protective environment minimizes exposure to Aspergillus and other opportunistic pathogens, making this a key precaution.

C. Place the client in a private room with negative-pressure airflow: Negative-pressure rooms are designed for clients with airborne infections to prevent pathogens from leaving the room. In contrast, protective environment rooms use positive-pressure airflow to prevent external pathogens from entering the room, protecting immunocompromised clients.

D. Wear an N95 respirator when giving the client direct care: N95 respirators are required when caring for clients with airborne infections such as tuberculosis. In a protective environment, the focus is on shielding the immunocompromised client from external pathogens, so standard precautions and proper hand hygiene are essential, but N95 use by staff is not routinely indicated

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Correct Answer is D

Explanation

A. Hypotension: Hypotension is more commonly associated with fluid volume deficit rather than fluid overload. When intravascular volume is low, cardiac output decreases, resulting in reduced blood pressure. In fluid volume excess, the circulating blood volume increases, which typically leads to elevated blood pressure due to increased preload and vascular pressure.

B. Weak, thready pulse: A weak, thready pulse usually occurs in hypovolemia, where there is insufficient circulating blood volume to maintain adequate perfusion. In fluid volume excess, the pulse is more likely to be bounding due to increased stroke volume and elevated intravascular pressure, reflecting increased cardiac workload.

C. Slow capillary refill: Delayed capillary refill indicates poor peripheral perfusion, often seen in dehydration, shock, or fluid volume deficit. In fluid volume excess, circulation is generally adequate or increased, and capillary refill is not typically delayed unless severe cardiac dysfunction or circulatory compromise develops.

D. Distended neck veins: Jugular venous distention (JVD) occurs when increased intravascular volume causes elevated central venous pressure. This leads to visible engorgement of the neck veins. JVD is a classic clinical sign of fluid overload and may also be accompanied by edema, hypertension, and pulmonary congestion.

A. Place the client in high-Fowler's position. B. Have the client use a trapeze bar when changing position. C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion. D. Increase the client's intake of carbohydrates.

Correct Answer is B

Explanation

A. Place the client in high-Fowler's position: High-Fowler’s position (sitting at 60–90 degrees) can increase pressure on the sacrum and coccyx, which are common sites for pressure ulcers. While upright positioning may help with respiratory function, it does not prevent skin breakdown and may actually contribute to pressure-related injury if repositioning is not frequent.

B. Have the client use a trapeze bar when changing position: A trapeze bar allows the client to lift and reposition themselves independently, reducing friction and shear forces on the skin. By enabling weight redistribution and promoting mobility, it helps prevent pressure ulcers in bony prominences and enhances circulation, which is essential for skin integrity in clients with limited lower extremity mobility.

C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion: Massaging areas of darker or reddened skin can cause further tissue damage by disrupting already compromised capillaries. The recommended approach is to relieve pressure, maintain skin hygiene and use protective padding, rather than massaging areas at risk for breakdown.

D. Increase the client's intake of carbohydrates: Adequate nutrition supports overall healing, but carbohydrates alone do not directly prevent skin breakdown. Protein and vitamins (such as vitamin C and zinc) are more critical for tissue repair and maintaining skin integrity. Nutrition is a supportive measure rather than a direct preventive intervention for pressure ulcers.

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