A nurse is planning care for a client who works in an environment with frequent exposure to pollutants. Which of the following should be included in the care plan?
Recommend using protective equipment
Advise the client to wash hands at the end of the day
Encourage the client to avoid all outdoor activity
Suggest the client change jobs
The Correct Answer is A
Choice A reason: Occupational health interventions prioritize the use of Personal Protective Equipment (PPE), such as specialized respirators or N95 masks, to mitigate the inhalation of particulate matter and chemical vapors. This primary prevention strategy reduces the risk of chronic obstructive pulmonary disease and systemic toxicity by establishing a physical barrier between the lung parenchyma and environmental toxins.
Choice B reason: While hand hygiene is a fundamental nursing intervention for infection control and removing surface contaminants, advising a client to wait until the end of the day is clinically insufficient. Frequent washing throughout the shift is necessary to prevent accidental ingestion or dermal absorption of hazardous pollutants, but it does not address the primary inhalation risk.
Choice C reason: Encouraging the total avoidance of outdoor activity is an unrealistic and sedentary lifestyle recommendation that can lead to cardiovascular deconditioning and psychological distress. Instead, the nurse should educate the client on monitoring air quality indices and scheduling outdoor activities during times when pollutant concentrations, such as ground-level ozone, are at their lowest.
Choice D reason: Suggesting a career change is often an impractical and extreme recommendation that may not be financially feasible for the client. The nursing role should focus on optimizing the current work environment through safety education, proper ventilation, and health surveillance rather than directing significant life decisions that fall outside the immediate clinical scope.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The S1 heart sound actually signals the beginning of systole, not diastole. Systole is the phase of the cardiac cycle during which the ventricles contract to eject blood into the systemic and pulmonary circulations. The sound is produced by the sudden cessation of blood flow as the atrioventricular valves close.
Choice B reason: Closure of the aortic and pulmonic semilunar valves produces the S2 heart sound, which marks the end of systole and the beginning of diastole. S2 is typically higher in pitch and shorter in duration than S1 and is best heard at the base of the heart using the diaphragm.
Choice C reason: The S1 sound, often described as a "lub," is primarily caused by the simultaneous closure of the mitral and tricuspid valves. As ventricular pressure rises above atrial pressure at the onset of contraction, these valves shut to prevent regurgitation, creating the vibrations that are audible during auscultation at the apex.
Choice D reason: A systolic heart murmur is an adventitious sound caused by turbulent blood flow, occurring between S1 and S2. While it occurs during systole, S1 itself is a normal physiological sound of valve closure and does not indicate the presence of a murmur, which is typically pathologic or functional.
Correct Answer is B
Explanation
Choice A reason: A temperature of 99.2 F is a low-grade fever, which is a common finding in pneumonia as the body mounts an immune response. While it requires monitoring, it does not pose an immediate threat to the client’s stability and is not the highest priority.
Choice B reason: Labored respirations indicate significant respiratory distress and potential gas exchange impairment. Following the "Airway, Breathing, Circulation" (ABC) priority framework, breathing issues are the most critical. Labored breathing at 24 breaths per minute suggests the client is struggling to maintain oxygenation and requires immediate intervention.
Choice C reason: A blood pressure of 134/78 is slightly elevated but remains within a range that does not require emergency intervention. In the context of pneumonia, this finding is secondary to the immediate need for respiratory stabilization and does not indicate acute hemodynamic collapse or shock.
Choice D reason: A heart rate of 105 is mildly tachycardic, which can be a compensatory response to fever, pain, or hypoxia. While important to note, the underlying cause in this scenario is likely the respiratory compromise, making the breathing pattern the more urgent clinical priority to address.
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