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 A

Explanation

A. The psychomotor domain involves the development of physical skills and the ability to manipulate objects. When the client performs a return demonstration of using the incentive spirometer, they are demonstrating their ability to coordinate their muscles and movements to correctly operate the device. This includes actions such as inhaling deeply, maintaining proper technique, and achieving the desired lung volume.

B The cognitive domain pertains to the acquisition and application of knowledge and intellectual skills. Understanding how the incentive spirometer works, its purpose in improving lung function post-surgery, and the correct technique for using it all fall under cognitive learning. The client must grasp the

Rationale behind using the spirometer to promote effective breathing and prevent complications like atelectasis.

C. Imitation involves observing and copying someone else's actions. In the context of using an incentive spirometer, the initial demonstration by the nurse serves as a model for the client to imitate. After receiving instructions and observing the nurse's demonstration, the client imitates the correct technique during the return demonstration. However, imitation alone does not fully capture the learning domain demonstrated by the client.

D. The affective domain focuses on attitudes, values, beliefs, and emotions. While using the incentive spirometer involves physical and cognitive skills, it also involves motivation and willingness to engage in the activity as prescribed by the healthcare provider. This domain encompasses the client's commitment to following through with spirometer use as part of their recovery and adherence to the healthcare plan.

A. Cardiac B. Gastrointestinal C. Respiratory D. Neurologic

Correct Answer is A

Explanation

A. Hyperkalemia can have significant cardiac effects, potentially leading to life-threatening arrhythmias such as bradycardia, heart block, ventricular tachycardia, or ventricular fibrillation. As potassium levels rise, it affects the electrical conduction of the heart, leading to changes in the ECG (electrocardiogram) and potentially causing fatal arrhythmias.

B. While hyperkalemia primarily affects the cardiovascular system, gastrointestinal symptoms can also occur. These may include nausea, vomiting, abdominal pain, and diarrhea. However, these symptoms are typically less severe compared to cardiac manifestations. Monitoring for gastrointestinal symptoms helps in assessing overall clinical status but is not as critical as assessing cardiac function in the context of hyperkalemia.

C. Respiratory symptoms are not typically associated with hyperkalemia unless severe acid-base disturbances are present. Potassium imbalance itself does not directly affect respiratory function. Therefore, while it is important to assess respiratory status in any client, it is not the priority in the context of hyperkalemia.

D. Hyperkalemia can affect the nervous system, leading to symptoms such as muscle weakness, tingling sensations, and even paralysis in severe cases. However, neurologic symptoms usually occur at higher potassium levels or in the presence of significant electrolyte imbalances affecting nerve function.

Monitoring for neurologic symptoms is important but is generally secondary to assessing cardiac status in the context of approaching severe hyperkalemia.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is A

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