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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The nurse is not responsible for obtaining informed consent. This is the responsibility of the healthcare provider performing the procedure, who must explain the risks, benefits, and alternatives to the client. The nurse may assist in ensuring the client has the necessary information, but the final responsibility for obtaining consent lies with the provider.
B. Explaining the risks and benefits of the procedure is part of the informed consent process.
The client needs to be informed about potential risks, benefits, and alternatives before giving consent.
C. This is correct. The nurse's role in the informed consent process is to witness the client's signature after the healthcare provider has explained the procedure, risks, and benefits. The nurse verifies that the client is signing voluntarily and understands the consent form, but the nurse does not provide the explanation.
D. Explaining the procedure to the client if they do not understand is essential for ensuring that the client has sufficient information to make an informed decision. This should be done in a clear and understandable manner.
Correct Answer is B
Explanation
A. The reported tympanic temperature of 37.1°C (98.8°F) is within normal range.
B. The blood pressure (BP) reading of 98/58 mm Hg indicates a relatively low diastolic pressure. Diastolic pressure is an important indicator of perfusion to vital organs, especially the coronary arteries and the brain. It's crucial to ensure that this reading is accurate.
C. The reported pulse rate of 92/min falls within the normal range for an adult at rest.
D. The reported respiratory rate of 18/min is within the normal range for an adult at rest.
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