The nurse observes a visitor of a client with meningitis. Which finding should concern the nurse?

The visitor is wearing gloves, gown and a mask while in the room.

The visitor is wearing only gloves while feeding the client in the room.

The visitor cleaned their hands when entering and leaving the room.

The visitor removed their protective gear before leaving the room.

Answer and Explanation

The Correct Answer is B

A. The visitor is wearing gloves, gown and a mask while in the room: This indicates proper use of standard and droplet precautions for a client with meningitis. Full personal protective equipment (PPE) helps prevent transmission of infectious agents. This demonstrates adherence to infection control guidelines.

B. The visitor is wearing only gloves while feeding the client in the room: Meningitis, particularly bacterial forms, is transmitted via respiratory droplets. Gloves alone do not protect against inhalation or contact with contaminated secretions. Inadequate PPE increases the risk of infection for the visitor and is a significant concern.

C. The visitor cleaned their hands when entering and leaving the room: Proper hand hygiene reduces the risk of transmitting pathogens to or from the client. Handwashing or using hand sanitizer is a key infection control measure. This practice supports patient and visitor safety.

D. The visitor removed their protective gear before leaving the room: Removing PPE before exiting the room is appropriate to prevent contamination of the external environment. Correct doffing of gear is essential to minimize spread of infectious agents.

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Correct Answer is C

Explanation

A. Temperature: The client has a mild fever (100.8°F / 38.2°C), which indicates possible infection or inflammation. While important, fever alone is less immediately life-threatening than hypoxemia.

B. Blood pressure: The client’s blood pressure is elevated at 141/89 mmHg, reflecting stage 2 hypertension. This is important for long-term management but is not an acute priority unless symptomatic or associated with organ dysfunction.

C. Oxygen saturation: An oxygen saturation of 91% on room air indicates hypoxemia, which can compromise tissue oxygenation and organ function. Immediate assessment and intervention, such as supplemental oxygen or further evaluation, are warranted to prevent deterioration.

D. Respiratory rate: The respiratory rate is mildly elevated at 22 breaths per minute, suggesting compensatory response to hypoxemia or infection. It should be monitored but does not take priority over oxygen saturation.

E. Heart rate: The client is tachycardic at 112 beats per minute, possibly as a compensatory response to fever, hypoxemia, or stress. While this finding is clinically relevant, it is secondary to addressing low oxygen saturation first.

A. Skip oral care due to unconsciousness. B. Use warm water and soap for bathing. C. Perform hygiene without donning gloves. D. Utilize unused linens from another client.

Correct Answer is B

Explanation

A. Skip oral care due to unconsciousness: Oral care is essential for unconscious clients to prevent mucosal breakdown, infection, and ventilator-associated complications. Skipping oral care increases the risk of bacterial overgrowth and aspiration. Consciousness level does not eliminate the need for hygiene.

B. Use warm water and soap for bathing: Warm water with mild soap promotes comfort, removes dirt and oils, and maintains skin integrity. Maintaining appropriate water temperature prevents hypothermia and enhances patient tolerance during hygiene procedures.

C. Perform hygiene without donning gloves: Gloves are necessary to protect both the client and nurse from pathogens present in body fluids or secretions. Performing hygiene without gloves increases the risk of infection transmission. Standard precautions must always be followed.

D. Utilize unused linens from another client: Using linens from another client violates infection control principles and can transmit pathogens. Each client requires their own clean linens to prevent cross-contamination.

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The nurse observes a visitor of a client with meningitis. Which finding should concern the nurse?

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