A nurse is planning care for a client who is on contact precautions. Which of the following actions should the nurse take?
Instruct visitors to put on a gown and gloves before entering the client's room.
Place a box of surgical masks outside the client's room.
Assign the client to a negative pressure room.
Ensure all gloves in the client's room are nonlatex.
The Correct Answer is A
A. Instruct visitors to put on a gown and gloves before entering the client's room: Contact precautions require the use of personal protective equipment, including gowns and gloves, to prevent transmission of infectious agents via direct or indirect contact. Visitors and healthcare personnel should don these items before entering the room.
B. Place a box of surgical masks outside the client's room: Masks are used for droplet or airborne precautions, not routine contact precautions. Providing masks outside the room is not necessary unless droplet or airborne infection is suspected.
C. Assign the client to a negative pressure room: Negative pressure rooms are required for airborne precautions, not contact precautions. Contact precautions focus on hand hygiene and barrier protection rather than specialized airflow.
D. Ensure all gloves in the client's room are nonlatex: While glove selection may depend on allergy considerations, using nonlatex gloves is not a requirement specifically for contact precautions. Standard or nitrile gloves are acceptable unless a latex allergy is present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Slurred speech: Slurred speech is typically associated with intoxication from central nervous system depressants, such as alcohol or opioids, rather than withdrawal. During withdrawal, the client is more likely to exhibit hyperactive or restless behavior.
B. Constricted pupils: Pupillary constriction (miosis) occurs with opioid intoxication. In contrast, opioid withdrawal usually causes dilated pupils (mydriasis) due to sympathetic nervous system overactivity.
C. Sedation: Sedation is a common effect of opioid use, not withdrawal. During withdrawal, clients are generally hyperalert, restless, and may experience insomnia rather than excessive sleepiness.
D. Yawning: Yawning is a classic sign of opioid withdrawal and reflects autonomic nervous system activation. It is often accompanied by lacrimation, rhinorrhea, sweating, and other early withdrawal symptoms.
Correct Answer is A
Explanation
A. "The test will determine if there is leaking amniotic fluid.": The nitrazine test is used to detect the presence of amniotic fluid in the vagina by measuring pH. A positive result indicates a more alkaline pH, suggesting rupture of membranes. This explanation accurately describes the purpose of the test to the client.
B. "Your bladder should be full prior to me performing this test.": A full bladder is not required for a nitrazine test. In fact, urine can interfere with results because it is acidic and may cause a false-negative reading, so the bladder should not influence the test outcome.
C. "I will be taking a blood sample to test for changes in your hormone levels.": The nitrazine test does not involve blood samples and is unrelated to hormone levels. It is performed using vaginal fluid to detect amniotic fluid, so this statement is inaccurate.
D. "If this test is positive you will be required to have a non-stress test.": A positive nitrazine test indicates ruptured membranes, which may require further assessment, but it does not automatically mandate a non-stress test. Additional evaluation and clinical judgment guide next steps rather than an automatic NST.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.