Standard precautions are established by the Center for Disease Control (CDC) How would a nurse explain when standard precautions are to be used with a client?
Standard precautions are to be used for any client, regardless of whether an infection has been identified.
Standard precautions are used when the client has an infection that is transmitted on air currents.
Standard precautions are to be used when the client has a pathogen that can spread via moist droplets.
Standard precautions are only used when there is an infection that is spread by indirect contact with an organism.
The Correct Answer is D
Choice A rationale:
Checking a restrained patient every 45 minutes might be too frequent and could interfere with the patient's rest and comfort, especially if the restraint is necessary for their safety. It could also lead to increased agitation and resistance from the patient, making it more challenging for the healthcare providers to manage the situation effectively.
Choice B rationale:
Checking on a restrained patient every 30 minutes is also too frequent for the reasons mentioned above. Patients need some time to rest and recover, and constant monitoring might be perceived as intrusive and threatening, potentially escalating the situation.
Choice C rationale:
Checking on a restrained patient every hour might not be sufficient, especially if the patient is at high risk of harming themselves or others. Waiting for an hour between checks could lead to dangerous situations, as a lot can happen in that time frame.
Choice D rationale:
Checking on a restrained patient every 2 hours strikes a balance between ensuring the patient's safety and respecting their privacy and comfort. It allows healthcare providers to monitor the patient's condition and intervene promptly if necessary while also giving the patient some space to rest and recover.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The spinal cord is not contained in the cranial cavity. The spinal cord is located within the spinal canal, which runs through the vertebral column, providing protection to the spinal cord.
Choice B rationale:
The heart is not contained in the cranial cavity. The heart is situated in the thoracic cavity, between the lungs, and is protected by the ribcage.
Choice C rationale:
The brain is contained in the cranial cavity. The cranial cavity, also known as the intracranial space, houses the brain and provides protection to this vital organ. The brain is the control center of the body, regulating various functions and processing sensory information.
Choice D rationale:
The stomach is not contained in the cranial cavity. The stomach is located in the abdominal cavity, which is situated below the diaphragm and above the pelvis. It is involved in the digestion of food and is not found in the cranial cavity.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Family members who smoke must be at least 10 ft from the client when oxygen is in use. Oxygen supports combustion, and smoking near an oxygen source can lead to a fire. Keeping family members who smoke at a safe distance minimizes this risk.
Choice B rationale:
Nail polish remover or hair spray should not be used near a client who is receiving oxygen. These substances contain flammable ingredients, which can ignite in the presence of oxygen. Instructing the client and those around them to avoid using such products prevents potential accidents.
Choice C rationale:
A "No Smoking" sign should be placed on the front door. This serves as a visual reminder to visitors and family members that smoking is prohibited in the vicinity, reducing the risk of fire when oxygen is in use. Clear communication through signage is essential in maintaining a safe environment.
Choice E rationale:
A fire extinguisher should be readily available in the home. Despite precautions, accidents can still happen. Having a fire extinguisher nearby allows for immediate response in case of a fire-related emergency, ensuring the safety of the client and those around them.
Choice D rationale:
Cotton bedding and clothing should be replaced with items made from wool. This statement is incorrect. There is no specific requirement to replace cotton items with wool for a client using oxygen. Instead, the focus should be on fire safety measures and ensuring that flammable materials are kept away from the oxygen source.
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