A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?
Anxiety over illness
Increased metabolic demands
Decreased drive to breathe
Infection destroying lung tissues
The Correct Answer is B
A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.
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Correct Answer is ["A","D"]
Explanation
A. Turning the clean pillowcase inside out over the hand holding it helps avoid contamination and allows easy application.
B. Soiled linens should be kept away from the nurse's uniform to prevent cross-contamination; hence, this is incorrect.
C. Sterile gloves are not required for bed-making; clean gloves may be used when handling soiled linens.
D. A modified mitered corner keeps the bed neat and helps secure the sheet, blanket, and spread.
E. Advising the patient of a lump when rolling over is not necessary for bed making, as the goal is to provide comfort without lumps.
Correct Answer is ["A","C","D","E"]
Explanation
A. Communication signs for airborne precautions are necessary to inform staff and visitors about the required precautions for TB, which is spread via airborne transmission.
B. A surgical mask is not adequate for TB; instead, an N95 respirator is required to filter out the airborne particles effectively.
C. The N95 respirator, gown, gloves, and eyewear are essential personal protective equipment for caring for a patient with tuberculosis. The N95 respirator specifically protects against inhaling infectious particles.
D. Negative-pressure airflow in the room is critical for tuberculosis patients to prevent airborne contaminants from spreading to other areas of the facility.
E. A private room is required to isolate the patient and reduce the risk of transmission to other patients and staff.
F. A communication sign for droplet precautions is not applicable as tuberculosis is primarily transmitted via airborne routes, not droplet transmission.