A nurse is teaching a group of assistive personnel about airborne precautions. Which of the following statements should the nurse make when caring for a client who has the measles?
A mask is not required when more than 3 feet from a client who requires airborne precautions.
A client who has varicella should be placed in a positive pressure room.
A respirator should be worn when entering the client's room.
A gown and gloves should be worn when providing direct care to the client.
The Correct Answer is C
Choice A reason: A mask is not sufficient to protect against airborne pathogens, such as the measles virus. A mask only filters out large droplets, but not the small particles that can remain suspended in the air. A mask should be worn when caring for a client who requires droplet precautions, such as influenza or pertussis.
Choice B reason: A client who has varicella should be placed in a negative pressure room, not a positive pressure room. A negative pressure room prevents the contaminated air from escaping the room and infecting others. A positive pressure room does the opposite: it prevents the outside air from entering the room and contaminating the client. A positive pressure room is used for clients who require protective isolation, such as those who are immunocompromised.
Choice C reason: A respirator should be worn when entering the client's room who has the measles. A respirator is a special type of mask that filters out both large and small particles, and provides a tight seal around the face. A respirator is required for clients who require airborne precautions, such as tuberculosis, varicella, or measles.
Choice D reason: A gown and gloves should be worn when providing direct care to the client who has the measles, but they are not specific to airborne precautions. A gown and gloves are part of standard precautions, which apply to all clients regardless of their diagnosis or infection status. A gown and gloves protect the nurse from contact with the client's blood, body fluids, secretions, and excretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Reminiscence therapy is a type of intervention that helps clients with Alzheimer's disease recall and share their past experiences, memories, and emotions. This can enhance their self-esteem, mood, and quality of life. By requesting a referral for this therapy, the nurse is advocating for the client's psychosocial needs and preferences.
Choice B reason: Performing an updated cognitive assessment on the client is not an example of advocacy, but rather a standard nursing practice. Cognitive assessments are used to monitor the client's cognitive status and progression of the disease. They do not necessarily reflect the client's wishes or interests.
Choice C reason: Providing assistance for the client when ambulating down the hall is not an example of advocacy, but rather a safety measure. The nurse is helping the client prevent falls and injuries, which are common risks for clients with Alzheimer's disease. This does not imply that the nurse is speaking up for the client or protecting their rights.
Choice D reason: Reorienting the client several times throughout the day is not an example of advocacy, but rather a therapeutic communication technique. The nurse is helping the client cope with confusion and disorientation, which are common symptoms of Alzheimer's disease. This does not indicate that the nurse is supporting the client's goals or values.
Correct Answer is B
Explanation
Choice A reason: Reassigning the AP to other clients on the unit is not an appropriate action for the nurse to take. This action does not address the issue of the breach of client confidentiality, and it may disrupt the continuity of care for the clients. The nurse should not punish the AP without giving them feedback and education.
Choice B reason: Instructing the AP to discontinue the conversation is an appropriate action for the nurse to take. This action stops the violation of client confidentiality and protects the client's privacy and dignity. The nurse should also remind the AP of the ethical and legal principles of confidentiality, and the consequences of violating them.
Choice C reason: Completing an incident report about the breach of client confidentiality is not an appropriate action for the nurse to take. This action is not necessary, as the breach was not intentional or harmful to the client. The nurse should document the incident in the AP's performance evaluation, and provide guidance and coaching to prevent future occurrences.
Choice D reason: Notifying the client's provider about the incident is not an appropriate action for the nurse to take. This action is not relevant, as the provider is not responsible for the AP's behavior or education. The nurse should notify the AP's supervisor or manager, and collaborate with them to address the issue.
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