The nurse is instructing family members of an immunosuppressed client who has been placed in a protective environment to wear gloves and a mask when visiting the client. The nurse is aware that this practice is important to prevent infection transmission from:
staff to family members.
hospital environment to family members.
family members to client.
client to family members.
The Correct Answer is C
C. This option correctly identifies the rationale behind the nurse's instruction. Immunosuppressed clients have a weakened immune system, making them highly vulnerable to infections. Family members may carry microorganisms on their hands, clothes, or respiratory secretions that can potentially transmit infections to the client. Wearing gloves and a mask helps reduce the risk of introducing pathogens to the client.
A. This option suggests that the risk is related to hospital staff transmitting infections to family members. While this is a concern in healthcare settings, it is not directly related to the specific situation described where family members are visiting an immunosuppressed client in a protective environment.
B. This option implies that the hospital environment itself poses a risk of infection transmission to family members. While hospitals can harbor various pathogens, the primary concern in this scenario is the transmission of infections to the immunosuppressed client from outside sources, including family members.
D. This option suggests that the client could transmit infections to family members. While this is theoretically possible depending on the specific infectious agent and the client's condition, the primary concern in a protective environment is preventing infections from entering the client's environment and affecting their health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.
A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.
C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.
D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.
Correct Answer is ["A","B","C","D"]
Explanation
A. Monitoring intake (fluids taken orally or intravenously) and output (urine, vomitus, diarrhea) helps assess fluid balance and hydration status. It is essential in clients with vomiting and diarrhea to prevent dehydration or fluid overload.
B. Vomiting and diarrhea can lead to dehydration and electrolyte imbalances, which may affect the skin and oral mucosa. Providing good mouth care (e.g., oral hygiene, hydration) and skin care (e.g., gentle cleansing, moisturizing) helps maintain comfort and prevent complications such as skin breakdown.
C. This may be appropriate depending on the severity of the client's condition and the healthcare provider's orders. Daily weights help monitor fluid balance and assess for changes in hydration status. However, in acute cases of vomiting and diarrhea, more frequent weights or other assessments of fluid status may be necessary.
D. Assessing the client's level of consciousness is important to monitor for signs of dehydration or electrolyte disturbances, which can affect neurological function. Changes in level of consciousness may indicate worsening dehydration or other complications that require prompt intervention.
E. Loop diuretics are medications used to increase urine output by inhibiting sodium reabsorption in the kidneys. However, they are not indicated for treating vomiting and diarrhea. In fact, administering diuretics could exacerbate fluid and electrolyte imbalances in a client who is already experiencing fluid loss through vomiting and diarrhea
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