A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?
Place the client on contact precautions.
Start a high-fiber diet.
Administer an oral steroid.
Make the client NPO.
The Correct Answer is D
Choice A rationale
Placing the client on contact precautions is not indicated based on the provided orders. Contact precautions are typically used for infections that are spread by direct or indirect contact, such as MRSA or C. difficile. The orders do not suggest the presence of such an infection.
Choice B rationale
Starting a high-fiber diet is not indicated. The client is already on a regular diet, and there is no mention of conditions that would necessitate a high-fiber diet, such as constipation or diverticulosis.
Choice C rationale
Administering an oral steroid is not indicated. The orders include Cefazolin, an antibiotic, and Metformin, an antidiabetic medication. There is no indication for an oral steroid, which is typically used for inflammatory conditions or autoimmune diseases.
Choice D rationale
Making the client NPO (nothing by mouth) is the correct action. This is likely due to the need for accurate blood glucose monitoring and the administration of IV antibiotics. Being NPO ensures that the client does not eat or drink anything that could interfere with these treatments.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Sending the UAP to be fitted for a particulate filter mask is unnecessary for droplet precautions. Particulate filter masks, such as N95 respirators, are required for airborne precautions, not droplet precautions.
Choice B rationale
Instructing the UAP that a standard face mask is sufficient is correct. Droplet precautions require a standard surgical mask to prevent the transmission of infections like bacterial meningitis. This allows the UAP to safely provide care without the need for a particulate filter mask.
Choice C rationale
Determining which staff members have fitted particulate filter masks is unnecessary for droplet precautions. This action is more relevant for airborne precautions, where particulate filter masks are required.
Choice D rationale
Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is incorrect. A standard face mask is sufficient for all aspects of care under droplet precautions.
Correct Answer is C
Explanation
Choice A rationale
Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it is not the primary action that indicates an understanding of standard precautions. Standard precautions emphasize hand hygiene as the most critical step in preventing infection transmission.
Choice B rationale
Donning a face mask before administering the medication is not necessary for standard precautions in home settings. Face masks are typically used in healthcare settings to prevent the spread of respiratory infections, but they are not required for routine medication administration at home.
Choice C rationale
Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the spread of infections and is a critical step in ensuring safe injection practices.
Choice D rationale
Removing the needle before discarding used syringes is not recommended. The entire needle and syringe should be disposed of in a sharps container to prevent needlestick injuries and contamination.