A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?

Stand 1.8 m (6 feet) away from the client.

Allow the client to ambulate in the hall.

Provide a positive-pressure airflow room.

Wear an N95 respirator mask.

Answer and Explanation

The Correct Answer is D

A.   Standing 1.8 m (6 feet) away from the client is not sufficient for airborne precautions.
Proper respiratory protection is required, such as an N95 mask.
B.   Allowing the client to ambulate in the hall is not a specific action related to airborne precautions. If the client needs to leave their room, they should wear a mask to prevent the spread of airborne particles.
C.   A positive-pressure airflow room is not typically required for airborne precautions.
However, ensuring proper ventilation in the room is important.
D.   Airborne precautions are required for clients with illnesses that spread via small droplets or dust particles that can remain in the air for extended periods. This includes diseases like tuberculosis, chickenpox, and measles. The nurse should wear an N95 respirator mask to provide protection against inhaling these particles.

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Correct Answer is C

Explanation

A. Having one nurse lift as the client pushes with his feet may not provide enough support and could potentially lead to an unsafe transfer, especially if the client is only partially able to assist.
B. Lifting the client under the shoulders with the assistance of another nurse may be appropriate for a different type of transfer, such as a sit-to-stand transfer, but it may not be the most suitable method for moving the client up in bed.
C. When a client is only partially able to assist, using a friction-reducing device, such as a slide or transfer board, is an effective and safe method. This device helps reduce the
friction between the client and the bed, making it easier to move the client up in bed.
D. Using a trapeze bar requires the client to have a certain level of strength and mobility, and may not be suitable for a client who is only partially able to assist.

A. Elevate the head of the bed no more than 45°. B. Use a transfer device to lift the client up in bed. C. Massage the skin over the client's bony prominences. D. Apply cornstarch to keep sensitive skin areas dry.

Correct Answer is A

Explanation

A. Elevating the head of the bed helps to reduce pressure on bony prominences, especially the sacral area, and can help prevent pressure ulcers. However, the head of the bed should not be elevated more than 30 degrees to 45 degrees to maintain skin integrity.
B. Using a transfer device is important for moving the client safely, but it is not specifically related to maintaining skin integrity.
C. Massaging the skin over bony prominences is not recommended as it can increase friction and shear, which can contribute to pressure ulcer development.
D. Applying cornstarch is not typically recommended for pressure ulcer prevention. It can create a moist environment that may contribute to skin breakdown, especially in areas where moisture can become trapped.

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A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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