a nurse is planning care for a client who has tuberculosis which of the following isolation precautions should the nurse implement
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing Quizlet

1. A client has tuberculosis, and the nurse is planning care. Which of the following isolation precautions should the nurse implement?

Correct answer: C

Rationale: The correct answer is C: Airborne. Tuberculosis is transmitted through the air, making it an airborne disease. Airborne precautions are crucial to prevent the spread of tuberculosis to others. These precautions include placing the client in a negative pressure room, wearing an N95 respirator mask, and ensuring proper ventilation to minimize the risk of transmission to healthcare workers and other clients. Choice A, Protective environment, is used for clients with compromised immune systems. Choice B, Contact precautions, are used for diseases spread by direct or indirect contact. Choice D, Droplet precautions, are for diseases transmitted through respiratory droplets, like influenza or pertussis.

2. A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?

Correct answer: C

Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.

3. A healthcare professional is preparing to administer an IM injection to a client. Which of the following techniques should the healthcare professional use to reduce discomfort?

Correct answer: B

Rationale: Administering the injection slowly is the recommended technique to reduce discomfort associated with IM injections. This approach allows the medication to disperse more gradually into the muscle, minimizing the sensation of pressure or pain during administration. Administering the injection slowly can also help prevent tissue damage and reduce the likelihood of injection site reactions.

4. When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?

Correct answer: D

Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.

5. A client is being assessed for dehydration. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.

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