A nurse is reinforcing teaching with an assistive personnel (AP) about a client who has pertussis. Which of the following instructions should the nurse include in the teaching?
Wear an N95 mask when in the client's room.
Wear a gown when caring for the client.
Wear a simple face mask when caring for the client.
Place the client in a negative air pressure room.
None
None
The Correct Answer is C
Choice A reason: This is a requirement for Airborne Precautions (used for smaller particles like those in Tuberculosis, Measles, or Varicella). Pertussis droplets are too large to remain suspended in the air, so a standard surgical mask is sufficient.
Choice B reason: Wearing a gown when caring for the client is not necessary, as pertussis is not transmitted by contact with body fluids or surfaces.
Choice C reason: Pertussis (Whooping Cough) is a highly contagious respiratory infection caused by the bacterium Bordetella pertussis. It is transmitted through large respiratory droplets expelled when an infected person coughs or sneezes. Because these droplets are heavy and typically travel only 3 to 6 feet before falling to the ground, Droplet Precautions are required.
Choice D reason: Placing the client in a negative air pressure room is not indicated, as pertussis is not classified as an airborne infection that requires isolation in a specially ventilated room.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: This is correct because suction equipment is essential for clearing the airway of secretions or vomitus during or after a seizure. The nurse should have suction equipment ready and accessible at the client's bedside at all times.
Choice B: This is incorrect because backboard is not needed for a client who has a seizure disorder. Backboard is used for immobilizing the spine in case of a suspected spinal injury.
Choice C: This is incorrect because padded tongue blades are not recommended for a client who has a seizure disorder. Padded tongue blades can cause injury to the teeth, gums, or tongue if inserted during a seizure. The nurse should never force anything into the mouth of a client who is having a seizure.
Choice D: This is incorrect because wrist restraints are not indicated for a client who has a seizure disorder. Wrist restraints can cause injury or skin breakdown if applied during a seizure. The nurse should never restrain or restrict the movements of a client who is having a seizure.
Correct Answer is C
Explanation
Choice A: This is incorrect because sore throat is not a finding that the nurse should report to the provider. Sore throat is a common and expected complication of bronchoscopy due to irritation from the endoscope. The nurse should provide oral care and offer ice chips or lozenges to soothe the throat.
Choice B: This is incorrect because blood pressure 110/78 mm Hg is not a finding that the nurse should report to the provider. Blood pressure 110/78 mm Hg is within the normal range and does not indicate any adverse effects from bronchoscopy. The nurse should monitor the vital signs and oxygen saturation of the client.
Choice C: This is correct because facial edema is a finding that the nurse should report to the provider. Facial edema can indicate an allergic reaction, airway obstruction, or mediastinal emphysema, which are serious and potentially life-threatening complications of bronchoscopy. The nurse should assess the airway, breathing, and circulation of the client and administer oxygen and medications as prescribed.
Choice D: This is incorrect because presence of gag reflex is not a finding that the nurse should report to the provider. Presence of gag reflex is an expected outcome of bronchoscopy, indicating that the anesthesia has worn off and the client can resume oral intake. The nurse should check the gag reflex before offering any food or fluids to the client.
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