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: Collecting the client's urine output every 24 hours is a task that the nurse can delegate to an AP. This task is within the AP's scope of practice and does not require clinical judgment or assessment. The nurse should provide clear instructions and expectations to the AP, and monitor and evaluate the client's fluid status and renal function.
Choice B reason: Administering the client's scheduled antitubercular medications is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should follow the five rights of medication administration and monitor the client for adverse effects and therapeutic outcomes.
Choice C reason: Assisting the client with speech therapy exercises is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires specialized knowledge and skills. The nurse should collaborate with the speech therapist and follow the prescribed plan of care for the client.
Choice D reason: Placing the client on airborne precautions is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should implement the infection control measures and educate the client and the AP about the rationale and the procedures.
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.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
