The client’s chest x-ray shows lung hyperinflation and left upper lobe pneumonia. What is the most likely diagnosis?

Choice A rationale

When a patient is placed on isolation precautions, the nurse should wear an N95 mask when caring for the patient. This is to protect the nurse from airborne particles that may be present in the patient’s environment.

Choice B rationale

Another important action the nurse should take is to place a container for soiled linens inside the patient’s room. This is to prevent the spread of infection from the patient’s room to other areas of the healthcare facility.

Choice C rationale

Wearing a sterile, water-resistant gown if within 3 feet of the patient is not necessary unless the patient has a condition that requires contact precautions, such as MRSA or VRE. In general, isolation precautions do not require the use of a sterile gown unless performing a sterile procedure.

Choice D rationale

Ensuring the patient’s room is well-ventilated is important for certain types of isolation precautions, such as airborne precautions for tuberculosis. However, it is not a standard action for all isolation precautions.

Choice A rationale

Inserting the needle at a 15-degree angle is not recommended for subcutaneous injections like heparin. The needle should be inserted at a 90-degree angle.

Choice B rationale

Aspirating for blood return before administration is not necessary when administering heparin.

Choice C rationale

Heparin should be administered into the abdominal fat layer, above the iliac crest and at least 2 inches away from the umbilicus.

Choice D rationale

Massaging the site after the injection is not recommended as it can cause bruising.