When using standard precautions, the nurse knows that standard precautions mandate what?
Rinsing gloves that become visibly soiled during use.
Using antimicrobial soap for routine handwashing.
Disinfecting hands immediately after removing gloves.
Keeping gloves on when touching environmental surfaces.
The Correct Answer is C
Choice A rationale:
Scabies is a skin infestation caused by the Sarcoptes scabiei mite. While it is contagious, it does not require the use of an N95 respirator mask. Standard precautions, including wearing gloves, are sufficient when caring for a client with scabies.
Choice B rationale:
Mycoplasmal pneumonia is a type of pneumonia caused by the bacteria Mycoplasma pneumoniae. It is typically spread through respiratory droplets and does not require the use of an N95 respirator mask. Standard precautions, including wearing a mask, are appropriate for this condition.
Choice C rationale:
Tuberculosis (TB) is a highly contagious bacterial infection caused by Mycobacterium tuberculosis. TB spreads through the air when an infected person coughs or sneezes. To prevent the inhalation of TB bacteria, healthcare workers should wear N95 respirator masks (or higher level respirators) when caring for clients with active TB disease.
Choice D rationale:
Scarlet fever is a bacterial illness that develops in some people who have strep throat. It is caused by group A Streptococcus bacteria and is typically treated with antibiotics. Scarlet fever does not require the use of an N95 respirator mask. Standard precautions, including wearing gloves and a mask, are appropriate when caring for a client with scarlet fever. Wearing an N95 respirator mask is crucial when caring for clients with airborne infectious diseases like tuberculosis. This type of mask is designed to filter out at least 95% of airborne particles, providing a high level of protection for healthcare workers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Keeping the walker at the end of the bed is inconvenient and increases the risk of falls. The walker should be easily accessible, ideally placed near where the client gets up from bed, to provide immediate support.
Choice B rationale: Fluorescent ceiling lights can be too harsh and cause glare, making it difficult for the client to see properly at night. Instead, using a nightlight or a softer, dimmable light source is recommended to provide safe, clear visibility.
Choice C rationale: Placing an area rug at the entry of the bathroom poses a tripping hazard. Loose rugs can easily shift and cause falls. It's better to use non-slip mats or secure carpeting to ensure safe footing, especially in areas prone to moisture.
Choice D rationale: Using a bath seat in the shower reduces the risk of slipping and falling. It provides a stable and secure place to sit while bathing, which is particularly important for clients with a history of falls or limited mobility.
Correct Answer is A
Explanation
Choice A rationale:
An oral temperature of 100°F (37.8°C) is within the normal range for body temperature, which typically ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C) While it's essential to monitor temperatures, this value does not require immediate attention.
Choice B rationale:
A respiratory rate of 30/min is a concerning finding. The normal respiratory rate for adults at rest is typically between 12 to 20 breaths per minute. A rate of 30/min suggests tachypnea (rapid breathing), which can be a sign of various underlying medical issues, including respiratory distress or metabolic acidosis. This requires immediate attention and further assessment.
Choice C rationale:
A radial pulse of 45 beats in 30 seconds can be translated to a pulse rate of 90 beats per minute, which falls within the normal range for adults (60 to 100 beats per minute) While it's important to monitor pulse rates, this value does not require immediate attention.
Choice D rationale:
A blood pressure of 114/74 mmHg is within the normal range for blood pressure in adults. Normal blood pressure typically ranges around 120/80 mmHg, but variations within a few points are considered normal. This blood pressure reading does not require immediate attention.
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