The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?

Transport the patient safely and quickly when going to the radiology department.

Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.

Place the patient in a room with negative airflow.

Wear a gown, gloves, face mask, and goggles for interactions with the patient.

Answer and Explanation

The Correct Answer is B

A) Transport the patient safely and quickly when going to the radiology department: While it's important to transport patients safely and efficiently, this action does not directly address the prevention of disease spread associated with contact precautions. Contact precautions primarily involve preventing direct or indirect contact with the patient's bodily fluids or contaminated surfaces.

B) Use a dedicated blood pressure cuff that stays in the room and is used for that patient only: This is the most appropriate action for preventing the spread of disease on contact precautions. Using dedicated equipment for the patient reduces the risk of cross-contamination between patients. It helps prevent the transmission of pathogens from one patient to another through contaminated equipment.

C) Place the patient in a room with negative airflow: Negative airflow rooms are typically used for patients on airborne precautions to prevent the spread of airborne pathogens. While maintaining appropriate airflow is important for infection control, it is not specific to contact precautions.

D) Wear a gown, gloves, face mask, and goggles for interactions with the patient: This option describes the appropriate personal protective equipment (PPE) to wear when caring for a patient on contact precautions. While it's important to wear PPE, using dedicated equipment for the patient is more directly related to preventing disease spread in this scenario

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Correct Answer is D

Explanation

A) "It's a good idea to help make sure your husband can sleep comfortably.":
This encourages the partner to administer medication, which can lead to overmedication and potential harm.

B) "Why do you think your husband needs more medication when he is asleep?":
This might cause the partner to feel defensive. It also does not provide the necessary education about the correct use of the PCA pump.

C) "Next time you think he needs more medication, call me and I'll push the button.":
This is inappropriate as well. It does not address the core issue that only the patient should be pressing the button to ensure safe and appropriate use of the PCA pump.

D) "Your husband should decide when more medication is needed.":
This educates the partner about the proper use of the PCA pump, emphasizing that only the patient should press the button to ensure they are receiving medication only when they feel pain. This minimizes the risk of overmedication and adverse effects.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30" to 45". D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.

B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.

C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.

D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.

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The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

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