The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?

Change bed linens on a daily basis.

Provide fresh drinking water every four hours.

Restrict visitors who have an upper respiratory infection.

Monitor intake and output every shift.

Answer and Explanation

The Correct Answer is C

C. This is the priority intervention because clients in protective isolation have compromised immune systems and are at high risk of infection. Upper respiratory infections can be transmitted easily through respiratory droplets, posing a significant risk to the client. Restricting visitors with such infections helps minimize the risk of introducing pathogens into the client's environment.

A. While maintaining cleanliness is important in any healthcare setting, changing bed linens daily may not be the highest priority in protective environment isolation unless there is a specific indication (e.g., soiled linens, contamination). It is essential to minimize unnecessary contact and potential sources of infection, but this is not the priority in the given context.

B. Hydration is important for all clients, but the frequency of providing fresh drinking water every four hours is generally a routine nursing care measure. Unless there are specific medical orders or client needs, this action is not directly related to the specialized care required in protective environment isolation.

D. Monitoring intake and output is important for assessing fluid balance and kidney function in hospitalized clients. However, in the context of protective isolation, where infection control is paramount, restricting visitors who pose a potential infectious risk takes precedence over routine monitoring tasks.

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Correct Answer is C

Explanation

C. Regular assessment of the IV site is crucial to detect early signs of infiltration. Signs of infiltration include swelling, coolness, pain, or blanching around the insertion site. Assessing the site allows nurses to intervene promptly if infiltration occurs, preventing further complications such as tissue damage or fluid overload.

A. Flushing the IV catheter with normal saline helps to maintain patency and prevent blockage of the catheter. It also ensures that medications are effectively delivered into the bloodstream. While this action is important for maintaining the function of the IV catheter, it primarily addresses patency rather than preventing infiltration directly.

B. Securing the IV catheter to the extremity with a securement device (such as tape or a transparent dressing) helps prevent accidental dislodgement or movement of the catheter. This reduces the risk of

mechanical irritation at the insertion site, which can contribute to infiltration. Proper securement also ensures that the catheter remains in place during movement or patient activities.

D. Proper technique during catheter insertion helps reduce the risk of infection and subsequent complications, but it also indirectly contributes to preventing infiltration. Contamination during insertion can lead to inflammation or infection at the site, which may increase the risk of infiltration due to compromised tissue integrity.

A. Open posture B. Lean away from client C. Establish eye contact D. Sit squarely facing client

Correct Answer is B

Explanation

B Leaning away from the client can convey disinterest, distraction, or a lack of engagement. It creates physical distance and may inhibit the client from feeling heard or valued. Thus, leaning away from the client can be a barrier to active listening as it diminishes the nurse's ability to fully attend to and understand the client's message.

A. An open posture, where the nurse's body is facing the client with arms uncrossed and relaxed, signals openness and receptivity. It encourages communication and shows the client that the nurse is engaged and attentive. Therefore, an open posture promotes active listening rather than serving as a barrier.

C. Eye contact is essential for effective communication and active listening. It demonstrates attentiveness, interest, and respect. Establishing eye contact helps the nurse to connect with the client and encourages them to continue sharing their thoughts and feelings. Therefore, eye contact supports active listening rather than hindering it.

D. Sitting squarely facing the client promotes engagement and shows that the nurse is focused on the client. It facilitates direct communication and helps the nurse to observe the client's nonverbal cues effectively. This posture encourages open dialogue and supports active listening rather than acting as a barrier.

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The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

Correct Answer is C

Explanation

Which of the following would be a barrier to active listening?

Correct Answer is B

Explanation

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