The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.)
Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms.
Dispose of supplies to prevent the spread of microorganisms.
Check the working order of the negative-pressure room for the airborne precaution patient on admission and at discharge.
Wash hands before entering and leaving both of the patients' rooms.
Be consistent in nursing interventions since there is only one difference in the precautions.
Have patients in airborne precautions wear a mask during transportation to other departments.
Correct Answer : A,B,C,D,F
A. Applying knowledge of disease processes is essential in preventing the spread of infections and understanding transmission routes.
B. Proper disposal of supplies is crucial in minimizing the risk of cross-contamination and infection spread.
C. Checking the negative-pressure system is critical to ensure it functions properly to contain airborne pathogens.
D. Hand hygiene is a key practice in preventing infection and should be performed before and after patient contact in both scenarios.
E. This statement is misleading; while some precautions may overlap, there are specific differences that must be addressed in interventions for airborne versus contact precautions.
F. It is important for patients in airborne precautions to wear a mask during transportation to prevent the spread of infectious particles.
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Correct Answer is D
Explanation
A. Chest physiotherapy is used to mobilize secretions and improve lung function, not specifically for increasing stroke volume or preload.
B. Diuretics would decrease preload by removing excess fluid, which is counterproductive in a patient with inadequate stroke volume related to decreased preload.
C. Vasodilators can further decrease preload and are not appropriate in this scenario where preload needs to be increased.
D. Intravenous (IV) fluids are administered to increase preload and improve stroke volume by enhancing the circulating blood volume.
Correct Answer is A
Explanation
A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.