An infection control nurse is assessing infection control precautions implemented by staff in a facility.
Select 2 client situations that require follow-up by the infection control nurse
Client 1
Client 2
Client 3
Client 4
Client 5
Correct Answer : A,D
A. Client 1 (Pertussis) requires droplet precautions, which include wearing surgical masks when within 3 feet of the client. The staff are wearing masks only within 1 foot, so this requires follow-up.
B. Client 2 (Clostridium difficile) requires contact precautions, including gown and gloves during care, which is correctly implemented.
C. Client 3 (Herpes simplex) requires contact precautions with gown and gloves, which is correctly implemented.
D. Client 4 (Mycobacterium tuberculosis) requires airborne precautions with a negative-pressure room (not positive airflow) and N95 respirators. The client is placed in a positive airflow room, which is incorrect and requires follow-up.
E. Client 5 (Streptococcal pharyngitis) requires droplet precautions, including private room and surgical mask during transport, which is correctly implemented.
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Related Questions
Correct Answer is D
Explanation
A.Assisting with ambulation is part of routine nursing care, not specifically an act of advocacy.
B.Reorienting the client helps with confusion but is also standard care for clients with cognitive impairment.
C.Performing a cognitive assessment is part of the nurse’s assessment role and does not involve speaking or acting on the client's behalf.
D. This demonstrates advocacy by promoting therapies that support the client's cognitive and emotional well-being. The nurse is taking action to support the client's preferences and needs beyond routine care.
Correct Answer is C
Explanation
A.Persistent nausea is uncomfortable but not immediately life-threatening.
B.Urine output of 32 mL/hr is low but may not be an urgent emergency without other signs.
C.An increased heart rate with a drop in blood pressure indicates possible shock or bleeding and requires immediate assessment.
D.Severe pain requires timely intervention but is not as immediately critical as vital sign instability.
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