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 B

Explanation

B. This question is also inclusive as it does not assume the client's sexual orientation or relationship status. It allows the client to disclose their current relationship status, whether they are in a relationship with a partner of the same or different gender, or if they are single.

A. This question uses assumes the client's gender and sexual orientation.

C. This question assumes a heterosexual relationship and also implies traditional gender roles. It may not be inclusive as it assumes that the client has a wife and further stereotypes the role of a wife as a cook.

D. This question assumes a heterosexual relationship and may not be inclusive of clients who do not have husbands or who are in same-sex relationships. It also reinforces traditional gender roles by assuming that a husband is the primary breadwinner or has a defined occupation.

A. exerts pressure against a stationary object B. lifts the body using a trapeze. C. walks briskly around the hospital unit. D. performs active range of motion to all joints.

Correct Answer is A

Explanation

A. Isometric exercises typically involve pushing or pulling against a stationary object or surface. This action creates muscle tension without joint movement.

B. Using a trapeze involves lifting the body and is more related to mobility assistance rather than isometric exercise. It typically involves movement and is not considered an isometric exercise.

C. Brisk walking is a cardiovascular exercise that involves movement and does not focus on muscle contraction without movement. It improves cardiovascular fitness and endurance rather than strength through isometric contraction.

D. Active range of motion exercises involve moving joints through their full range of motion using muscle strength. This is different from isometric exercises, which involve static muscle contractions without joint movement.

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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

Which of these questions, used by the nurse, shows appropriate use of inclusive language?

Correct Answer is B

Explanation

The nurse is teaching a client about isometric exercise. Which activity indicates that the client understands the teaching? The client:

Correct Answer is A

Explanation

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