A nurse is planning care for a client who is on droplet precautions. Which of the following actions should the nurse take for this client?

Ensure all gloves in the client’s room are nonlatex.

Equip the client’s room with a HEPA filtration system.

Place a box of surgical masks outside the client’s room.

Assign the client to a negative pressure room.

Answer and Explanation

The Correct Answer is C

Choice A reason: Nonlatex gloves are relevant for allergies, not droplet precautions, which require masks. Placing surgical masks is key. Assuming gloves are priority risks neglecting respiratory protection, potentially increasing transmission, critical to avoid in ensuring effective infection control for droplet-borne illnesses in healthcare settings.

Choice B reason: HEPA filtration is for airborne precautions, not droplet, which needs masks. Placing surgical masks is correct. Assuming HEPA is needed risks misapplying resources, potentially diverting focus from droplet transmission prevention, critical to prevent in ensuring proper infection control for clients on droplet precautions.

Choice C reason: Placing surgical masks outside the room is essential for droplet precautions, ensuring staff and visitors wear masks to prevent respiratory transmission. This is critical for infection control, reducing spread, protecting others, and adhering to CDC guidelines for managing droplet-borne infections in healthcare settings.

Choice D reason: Negative pressure rooms are for airborne precautions, not droplet, which requires masks. Assuming negative pressure is needed risks inappropriate room assignment, potentially increasing transmission, critical to avoid in ensuring correct infection control measures for clients on droplet precautions in healthcare facilities.

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Correct Answer is C

Explanation

Choice A reason: A temperature of 37.6°C is normal post-surgery, not requiring reporting; low urinary output is urgent. Assuming temperature is concerning risks overlooking renal issues, potentially delaying intervention, critical to avoid in ensuring comprehensive postoperative monitoring and client safety after abdominal surgery.

Choice B reason: Serous drainage is expected post-abdominal surgery, indicating normal healing, not requiring reporting. Low urinary output is priority. Assuming drainage is urgent risks misprioritizing, potentially neglecting renal complications, critical to prevent in ensuring proper postoperative care and recovery in surgical clients.

Choice C reason: Urinary output of 20 mL/hr is below normal (30-50 mL/hr), indicating potential renal impairment or dehydration post-surgery, requiring immediate reporting. This ensures timely intervention, critical for preventing kidney injury, maintaining fluid balance, and supporting recovery in clients post-abdominal surgery.

Choice D reason: Blood pressure of 100/70 mm Hg is low but not critical unless symptomatic; low urinary output is more urgent. Assuming blood pressure requires reporting risks overlooking renal issues, critical to avoid in ensuring prioritized monitoring and intervention in postoperative abdominal surgery clients.

A. A blister-like area. B. An area of ecchymosis. C. A cool, blanched area. D. An elevated, hardened area.

Correct Answer is D

Explanation

Choice A reason: A blister-like area is not indicative of a positive Mantoux test, which shows induration; blisters suggest irritation. Assuming blisters are positive risks misdiagnosis, potentially missing tuberculosis exposure, critical to avoid in ensuring accurate screening and follow-up in clients tested for TB.

Choice B reason: Ecchymosis (bruising) is not a positive Mantoux result; induration indicates exposure. Assuming ecchymosis is positive risks incorrect interpretation, potentially overlooking tuberculosis risk, critical to prevent in ensuring proper screening, diagnosis, and follow-up for clients undergoing TB skin testing.

Choice C reason: A cool, blanched area suggests no reaction, not a positive Mantoux test, which requires induration. Assuming blanching is positive risks missing exposure, critical to avoid in ensuring accurate tuberculosis screening, guiding appropriate diagnostic follow-up, and protecting client and public health.

Choice D reason: An elevated, hardened area (induration) at 72 hours indicates a positive Mantoux test, suggesting TB exposure, requiring further evaluation. This is critical for accurate screening, ensuring timely diagnosis, preventing disease spread, and guiding follow-up in clients tested for tuberculosis exposure.

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A nurse is planning care for a client who is on droplet precautions. Which of the following actions should the nurse take for this client?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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