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 C
Explanation
Choice A rationale:
Pulse pressure is the difference between systolic and diastolic blood pressure and is not related to changing positions or the symptoms described in the scenario.
Choice B rationale:
Essential hypertension is a chronic medical condition characterized by elevated blood pressure levels persistently exceeding 140/90 mmHg. It is not directly related to positional changes or postural hypotension symptoms.
Choice C rationale:
Postural (orthostatic) hypotension occurs when a person experiences a sudden drop in blood pressure upon standing up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, and fainting. Slowly changing positions is essential in managing postural hypotension because abrupt movements can worsen these symptoms. Educating the client about the importance of gradual position changes is crucial in preventing or minimizing postural hypotension-related symptoms.
Choice D rationale:
Pre-hypertension refers to blood pressure levels that are higher than normal but not high enough to be diagnosed as hypertension. It does not directly relate to the symptoms described in the scenario.
Correct Answer is B
Explanation
Choice A rationale:
A pulse rating of 2+ is not considered an expected finding. It indicates a weaker pulse, which requires further assessment.
Choice B rationale:
A pulse rated as 2+ means the pulse is full volume and bounding. In clinical practice, a 2+ pulse is considered normal and signifies a pulse that is easily palpable and has a normal strength. This is an essential finding for the nurse to understand because it reflects the circulatory status of the client. A 2+ pulse suggests adequate perfusion and a healthy heart pumping blood effectively.
Choice C rationale:
A pulse rating of increased and strong corresponds to a higher numeric value on the scale, indicating a stronger pulse. A 2+ pulse is not categorized as increased but is rather a moderate strength pulse.
Choice D rationale:
A pulse rating of 2+ does not suggest an absent pulse. An absent pulse would mean that no pulse can be felt, which is a critical situation requiring immediate medical attention.
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