A nurse is placing a patient on isolation precautions. The patient’s diagnostic results at 1400 are given.
Which of the following actions should the nurse take?

Wear an N95 mask when caring for the patient.

Place a container for soiled linens inside the patient’s room.

Wear a sterile, water-resistant gown if within 3 feet of the patient.

Ensure the patient’s room is well-ventilated.

Answer and Explanation

Correct Answer : A,B

Choice A rationale

When a patient is placed on isolation precautions, the nurse should wear an N95 mask when caring for the patient. This is to protect the nurse from airborne particles that may be present in the patient’s environment.

Choice B rationale

Another important action the nurse should take is to place a container for soiled linens inside the patient’s room. This is to prevent the spread of infection from the patient’s room to other areas of the healthcare facility.

Choice C rationale

Wearing a sterile, water-resistant gown if within 3 feet of the patient is not necessary unless the patient has a condition that requires contact precautions, such as MRSA or VRE. In general, isolation precautions do not require the use of a sterile gown unless performing a sterile procedure.

Choice D rationale

Ensuring the patient’s room is well-ventilated is important for certain types of isolation precautions, such as airborne precautions for tuberculosis. However, it is not a standard action for all isolation precautions.

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Correct Answer is A

Explanation

Choice A rationale

Using a bed exit alarm system is a common intervention to minimize the risk of injury in patients with dementia. These systems alert staff when a patient attempts to leave the bed, allowing for timely intervention to prevent falls.

Choice B rationale

Raising four side rails while the patient is in bed is not a recommended practice. This could be considered a form of restraint and could increase the risk of injury if the patient attempts to climb over the rails.

Choice C rationale

Applying one soft wrist restraint is not a recommended practice for patients with dementia. Restraints should be used as a last resort and only when necessary for the patient’s safety.

Choice D rationale

Dimming the lights in the patient’s room is not a recommended practice to minimize the risk of injury in patients with dementia. Adequate lighting can help prevent falls and other accidents.

A. Client 1 B. Client 2 C. Client 3 D. Client 4 E. Client 5

Correct Answer is C

Explanation

Choice A rationale: Client 1 is admitted with a new diagnosis of rheumatoid arthritis. While this condition can cause discomfort and requires management, it is a chronic condition that does not typically present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

Choice B rationale: Client 2 has a history of hyperlipidemia and has been administered Atorvastatin 20 mg PO as prescribed. Hyperlipidemia is a chronic condition that requires ongoing management, but it does not typically present an immediate threat to the client’s health. The fact that the client has been administered their medication as prescribed suggests that their condition is currently being managed effectively. Therefore, while this client will need to be monitored to ensure that their medication continues to be effective, they are not the highest priority at this time.

Choice C rationale: Client 3 is 1 day postoperative and reports pain as 8 on a scale of 0 to 10, even after Morphine 5 mg subcutaneous was administered as prescribed. This indicates that the client’s pain is not well controlled and could be a sign of complications. Therefore, immediate assessment is required. This client should be the nurse’s highest priority.

Choice D rationale: Client 4 is admitted with a new diagnosis of heart failure. Heart failure is a serious condition that can have life- threatening complications. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

Choice E rationale: Client 5 has a stage 2 pressure injury on the left heel. Pressure injuries can lead to serious complications, including infection and tissue necrosis. However, a stage 2 pressure injury is a relatively minor injury that is unlikely to present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their pressure injury, they are not the highest priority at this time.

Choice F rationale: Client 6 is admitted with a new diagnosis of diabetes mellitus. Diabetes is a chronic condition that requires ongoing management. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

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A nurse is placing a patient on isolation precautions. The patient’s diagnostic results at 1400 are given.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has dementia. What intervention should the nurse take to minimize the risk of injury to the patient?

Correct Answer is A

Explanation

A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions. Exhibits Based on the Nurses’ Notes, which client should the nurse assess first? Please select the correct client number from the choices below:

Correct Answer is C

Explanation

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A nurse is placing a patient on isolation precautions. The patient’s diagnostic results at 1400 are given.
Which of the following actions should the nurse take?