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 ["B","C","D","E","F"]

Explanation

A. Potassium level is incorrect because it is within the normal range and does not affect wound healing directly.
B. Prealbumin level is correct because it is low, indicating malnutrition and poor protein intake, which are essential for tissue repair and immune function.
C. History of diabetes mellitus is correct because it causes impaired blood flow, increased risk of infection, and delayed inflammatory response, which all hinder wound healing.
D. History of hyperlipidemia is correct because it causes atherosclerosis and reduced blood supply to the affected area, which limits oxygen and nutrient delivery to the wound.
E. Wound infection is correct because it increases inflammation, tissue damage, and metabolic demands, which prolong the healing process and may lead to complications.
F. Decreased pedal perfusion is correct because it indicates poor circulation to the lower extremities, which impairs wound healing by reducing oxygen and nutrient delivery to
the wound.
G. Fasting blood glucose is incorrect because it is not a direct cause of delayed wound healing, but rather a reflection of the client's diabetes management. However, high blood glucose levels can impair wound healing by affecting blood flow, immune function, and collagen synthesis.

A. Providing oral care B. Emptying urine from an indwelling urine collection bag C. Placing oral medication tablets into a client's hand D. Delivering a food tray to a client who has AIDS E. Changing an ostomy pouch

Correct Answer is ["A","B","E"]

Explanation

A. Providing oral care involves contact with mucous membranes and saliva, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
B. Emptying urine from an indwelling urine collection bag involves contact with urine, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
C. Placing oral medication tablets into a client's hand does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to wear
gloves for this task.
D. Delivering a food tray to a client who has AIDS does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to wear gloves for this task. However, the nurse should follow standard precautions and wash their hands before and after contact with any client.
E. Changing an ostomy pouch involves contact with feces, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.

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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

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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