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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
B. Physician and nurse practitioner orders specify the medical treatments, medications, and interventions prescribed for the client. These orders are essential for guiding care at the subacute care facility and are a critical part of the legal health record.
C. A living will, also known as an advance directive, outlines the client's preferences for medical treatment and care in the event they are unable to communicate their wishes. It is a legal document that guides decision-making regarding end-of-life care.
D. Vital sign flow records document the client's vital signs over time, including measurements such as blood pressure, heart rate, respiratory rate, and temperature. These records are essential for monitoring the client's health status and detecting trends or changes.
F. Nurses' assessments document the nursing observations, assessments, and interventions provided to the client. These assessments are crucial for ongoing nursing care and should be included in the legal health record.
A. Event or unusual occurrence reports document any incidents or deviations from the standard of care that occur during the client's hospitalization. These reports are important for quality improvement and risk management but are typically not included in the legal health record unless they directly impact the client's care.
E. Proof of residence or property ownership documents are not typically included in the legal health record. These documents are unrelated to the client's medical care and are considered personal or administrative records.
Correct Answer is D
Explanation
D. These effects are not the primary intended outcomes of the medication, but are known possible reactions that can occur in addition to the main therapeutic effect.
A. Synergistic effects refer to the combined action of two or more substances or medications that results in an effect greater than the sum of their individual effects.
B. Adverse effects are unintended and potentially harmful effects of a medication, even when the medication is used at therapeutic doses and in the correct manner.
C. Therapeutic effects are the desired and beneficial effects of a medication that contribute to treating or managing a medical condition. These effects are intended and typically guide the prescribing and administration of medications.
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