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 B
Explanation
Choice A reason: A nurse refusing to actively participate during an elective abortion procedure scheduled for their client is not a behavior that indicates a need for further education. The nurse has the right to conscientious objection, which means they can decline to perform or assist in a procedure that violates their moral or religious beliefs. The nurse should inform the charge nurse of their objection and request to be reassigned to another client.
Choice B reason: A nurse explaining to a client's family that a DNR order includes withholding comfort measures is a behavior that indicates a need for further education. The nurse is providing false and misleading information that can cause harm and distress to the client and the family. A DNR order only means that no cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) will be initiated in the event of a cardiac or respiratory arrest. A DNR order does not affect the provision of other treatments, such as pain management, hydration, nutrition, oxygen, or emotional support.
Choice C reason: A nurse informing a confused client who wants to go home that they are going to stay at the facility until they are better is not a behavior that indicates a need for further education. The nurse is using therapeutic communication and providing reassurance to the client. The nurse is also respecting the client's autonomy and right to refuse treatment, as long as the client is competent and informed. The nurse should assess the client's mental status and decision-making capacity, and involve the client's family or surrogate decision-maker if needed.
Choice D reason: A nurse giving prescribed opioids to a client who has a terminal illness and respirations of 8/min is not a behavior that indicates a need for further education. The nurse is following the principle of beneficence, which means doing good and preventing harm to the client. The nurse is also following the principle of double effect, which means that an action that has both a good and a bad effect is morally permissible if the good effect outweighs the bad effect. The nurse is providing adequate pain relief to the client, even if it may hasten their death. The nurse should monitor the client's vital signs and level of consciousness, and adjust the opioid dose as prescribed.
Correct Answer is C
Explanation
Choice A reason: Asking the provider to delay the client's discharge home for a few more days is not an appropriate action for the nurse to take. This would not address the partner's concerns or the client's needs. It would also increase the risk of hospital-acquired infections and complications for the client.
Choice B reason: Seeking out another family member to assist the client's partner with care is not an appropriate action for the nurse to take. This would not respect the partner's autonomy or the client's wishes. It would also assume that there is another family member who is willing and able to provide care.
Choice C reason: Contacting a case manager to discuss hospice options is the appropriate action for the nurse to take. This would provide the client and the partner with information and support regarding end-of-life care. Hospice care focuses on improving the quality of life and comfort of clients with terminal illnesses and their families.
Choice D reason: Advising the partner to place the client in a long-term care facility is not an appropriate action for the nurse to take. This would not respect the partner's feelings or the client's preferences. It would also imply that the nurse is judging the partner's decision or ability to care for the client.
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