A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
A negative-pressure isolation room.
A private room.
A semi-private room with a client who has pediculosis capitis.
A positive-pressure isolation room.
The Correct Answer is B
Choice A: A Negative-Pressure Isolation Room
A negative-pressure isolation room is typically used for patients with airborne infections, such as tuberculosis, to prevent the spread of infectious particles through the air. Scabies, however, is spread through direct skin-to-skin contact or contact with contaminated items, not through the air. Therefore, a negative-pressure room is not necessary for a client with scabies.
Choice B: A Private Room
Placing the client in a private room is the appropriate action. This helps to prevent the spread of scabies to other patients and staff. Scabies is highly contagious, and isolating the affected individual minimizes the risk of transmission. The client should remain in the private room until the treatment regimen is complete and they are no longer contagious.
Choice C: A Semi-Private Room with a Client Who Has Pediculosis Capitis
A semi-private room with a client who has pediculosis capitis (head lice) is not appropriate. While both conditions involve parasites, they are different and require separate management and treatment protocols. Placing two clients with different contagious conditions in the same room increases the risk of cross-contamination and complicates infection control measures.
Choice D: A Positive-Pressure Isolation Room
A positive-pressure isolation room is used to protect immunocompromised patients from external contaminants by ensuring that air flows out of the room rather than in. This type of room is not suitable for a client with scabies, as it does not address the mode of transmission for this condition.
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Correct Answer is D
Explanation
Choice A reason: Administer 50,000 units of heparin by IV bolus every 12 hours:
This dosage is incorrect and potentially dangerous. Heparin dosing must be carefully calculated based on the patient’s weight and coagulation test results. Standard practice involves adjusting the dose according to the aPTT levels to maintain therapeutic anticoagulation.
Choice B reason: Have vitamin K available on the nursing unit:
Vitamin K is the antidote for warfarin, not heparin. The antidote for heparin is protamine sulfate. Having the correct antidote available is crucial for managing potential bleeding complications associated with heparin therapy.
Choice C reason: Use tubing specific for heparin sodium when administering the infusion:
While it is important to use appropriate tubing for any IV medication, there is no specific tubing required exclusively for heparin sodium. Standard IV tubing is typically sufficient.
Choice D reason: Check the activated partial thromboplastin time (aPTT) every 6 hours:
This is correct. Monitoring aPTT levels is essential when administering a continuous heparin infusion. The aPTT test measures the time it takes for blood to clot and helps ensure that the heparin dose is within the therapeutic range. Regular monitoring helps prevent both under- and over-anticoagulation, reducing the risk of clotting or bleeding complications.
Correct Answer is ["A","B","C"]
Explanation
Choice A: Pneumonia
Reason:Postoperative patients, especially those who have undergone abdominal surgery, are at a higher risk of developing pneumonia. This is due to the fact that pain and discomfort can prevent them from taking deep breaths and coughing effectively, which are essential actions to clear the lungs of secretions. The nurse’s notes indicate that the client is refusing to turn and cough due to pain, which further increases the risk of pneumonia. The use of splinting with a pillow when coughing is a technique to help reduce pain and encourage effective coughing, but if the client refuses to comply, the risk remains high.
Choice B: Deep Vein Thrombosis (DVT)
Reason: Deep vein thrombosis is a significant risk for postoperative patients, particularly those who are immobile. The client in this scenario has refused to wear intermittent pneumatic compression devices, which are designed to prevent DVT by promoting blood circulation in the legs. Immobility and the lack of these devices increase the risk of blood clots forming in the deep veins of the legs. If a clot forms and travels to the lungs, it can cause a life-threatening pulmonary embolism. The nurse’s notes emphasize the importance of these devices, but the client’s refusal to use them puts them at a higher risk of developing DVT.
Choice C: Pressure Ulcers
Reason:Pressure ulcers, also known as bedsores, are a common complication for patients who are immobile for extended periods. The client’s refusal to change positions increases the risk of pressure ulcers developing on areas of the body that are in constant contact with the bed. These ulcers can be painful and lead to serious infections if not managed properly. Regular turning and repositioning are crucial in preventing pressure ulcers, and the nurse’s notes highlight the importance of this practice.
Choice D: Urinary Retention
Reason:While urinary retention can be a postoperative complication, it is less likely in this scenario because the client has a Foley catheter in place, which is draining to a bedside bag. The catheter helps to ensure that the bladder is emptied regularly, reducing the risk of urinary retention. Therefore, this is not one of the primary risks for this client based on the provided information.
Choice E: Hemorrhage
Reason:Hemorrhage, or excessive bleeding, is a potential risk after any surgery, including a total abdominal hysterectomy. However, the nurse’s notes indicate that the abdominal dressing is dry and intact, and only scant vaginal bleeding has been observed. This suggests that there is no significant bleeding at this time. While hemorrhage is always a concern, the current observations do not indicate an immediate risk.
