The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Middle-aged man experiencing the acute phase of myocardial infarction (MI)

Older adult with a history of dementia admitted for dehydration

Young adult in the rehabilitative phase after arthroscopic surgery

Middle-aged woman just diagnosed with terminal lung cancer

Answer and Explanation

The Correct Answer is A

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.

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Correct Answer is D

Explanation

A. “The precautions will protect me and help my blood count recover faster.”: While protective precautions are meant to safeguard the client from infections, this statement does not specifically address the necessary actions or behaviors that need to be followed to maintain reverse isolation. Recovery of blood counts is a complex process that depends on multiple factors, including the underlying condition and treatment.

B. "Persons entering the room with colds should stay at least 3 feet from me.": This statement is not sufficient for reverse isolation. Individuals entering the room should be free of any respiratory illnesses, and maintaining a distance may not be adequate protection. Ideally, anyone entering the room should be healthy and ideally wearing appropriate protective gear, such as masks, to reduce the risk of transmitting infections.

C. "My family plans to bring flowers from my garden to help me feel better.": Bringing flowers from outside can introduce pathogens and compromise the sterile environment necessary for a client in reverse isolation. This statement demonstrates a lack of understanding of the precautions required to maintain a safe environment.

D. "Persons entering my room should perform hand hygiene before entering.": This statement accurately reflects an understanding of the precautions needed in reverse isolation. Hand hygiene is critical in preventing the introduction of pathogens into the sterile environment of a client with a severely depressed neutrophil count. It helps to minimize the risk of infections, which is the primary goal of reverse isolation.

A. Discard the dressing in the bedside trash receptacle. B. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. C. Double-bag the dressing in clear bags and label it "biohazard". D. Dispose of the dressing in a biohazardous waste container.

Correct Answer is D

Explanation

A. Discard the dressing in the bedside trash receptacle: This option is inappropriate because it poses a risk of contamination and infection. Regular trash receptacles are not equipped to handle materials that may be contaminated with blood or infectious waste.

B. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle: While enclosing the dressing in a plastic bag is a step toward containment, discarding it in the regular trash still poses a contamination risk and is not compliant with infection control standards for hazardous materials.

C. Double-bag the dressing in clear bags and label it "biohazard": Although double-bagging and labeling would provide additional precautions, this method is not the standard practice for disposing of contaminated wound dressings. It is more appropriate to use designated biohazard containers for infectious waste rather than using bags.

D. Dispose of the dressing in a biohazardous waste container: This is the correct action. Biohazardous waste containers are specifically designed to safely dispose of materials that may be contaminated with blood, body fluids, or infectious agents. Proper disposal helps to prevent the spread of infection and ensures compliance with safety regulations in healthcare settings.

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The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?

Correct Answer is D

Explanation

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Correct Answer is D

Explanation

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

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