An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?
"Wear a mask when entering the client's room."
"Gloves are not necessary if you wash your hands well."
"Place a mask on the client when you check her vital signs."
"Wear a gown whenever you come in close contact with the client."
The Correct Answer is A
A. Wearing a mask helps prevent the spread of respiratory droplets that may contain infectious pathogens, such as those causing pneumonia. It protects both the client from potential pathogens carried by the AP and the AP from potential exposure to the client's respiratory secretions.
B. Gloves should be worn when there is a risk of contact with the client's body fluids, including respiratory secretions, to prevent transmission of infectious agents. Hand hygiene (washing hands well) is important but does not replace the need for gloves in situations where there is a risk of exposure to bodily fluids.
C. Placing a mask on the client would not typically be required unless the client is coughing excessively and the mask is intended to contain respiratory droplets. However, the focus of precautions should primarily be on protecting the AP.
D. Wearing a gown may be necessary if there is a risk of contamination with respiratory secretions or if the AP anticipates contact with the client's body fluids. However, it is not specifically required for routine vital sign measurement unless there is visible contamination or extensive contact with the client's secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The oliguric phase of AKI typically lasts longer than 2 days. It can extend from several days to weeks, depending on the underlying cause and the response to treatment.
B. During the oliguric phase of AKI, urine output is significantly reduced. Typically, urine output is less than 400 mL per day, but it can vary widely based on the severity of kidney injury and individual factors.
C. The oliguric phase of AKI usually begins within a few days to a week after the initial injury. It is characterized by a sudden decrease in urine output and may be accompanied by electrolyte imbalances and fluid overload.
D. During the oliguric phase of AKI, there is typically a buildup of waste products such as blood urea nitrogen (BUN) and creatinine in the blood. These levels rise because the kidneys are unable to effectively filter and excrete waste products. Therefore, BUN and creatinine levels usually increase during the oliguric phase.
Correct Answer is D
Explanation
A. Protein intake, especially animal protein (such as meat and dairy), can increase the excretion of calcium and other minerals into the urine, potentially leading to the formation of certain types of kidney stones (like calcium stones). Therefore, clients with a history of kidney stones are generally advised to moderate their intake of animal protein.
B. Some types of tea, particularly black tea, contain oxalates, which are substances that can contribute to the formation of calcium oxalate kidney stones in susceptible individuals. Therefore, clients with kidney
stones may be advised to limit their intake of tea, especially if they have a history of calcium oxalate stones.
C. High dietary sodium intake can increase calcium excretion in the urine, which may lead to the formation of calcium-containing kidney stones. Therefore, clients with kidney stones are often advised to reduce their sodium intake to help prevent stone formation.
D. Adequate fluid intake, primarily in the form of water, is crucial for preventing kidney stones. Increased water intake helps dilute urine and reduces the concentration of stone-forming substances, making it less likely for crystals to form and grow into stones. The goal is typically to produce at least 2 to 2.5 liters (about 8 to 10 cups) of urine per day.
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