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 A
Explanation
A. Hyperkalemia can lead to dangerous cardiac arrhythmias and other heart-related complications due to its effect on the electrical conduction system of the heart, making cardiac assessment the priority.
B. While neurological assessment is important in various conditions, it is secondary to assessing cardiac status in hyperkalemia.
C. Gastrointestinal symptoms can occur with hyperkalemia, but they do not pose an immediate life-threatening risk like cardiac issues do.
D. Respiratory assessment is essential in many contexts, but the immediate threat of hyperkalemia lies in its impact on heart function, making cardiac assessment the most critical.
Correct Answer is D
Explanation
A. Sequential compression devices are used to prevent deep vein thrombosis and are not relevant for assessing orthostatic hypotension.
B. Elastic stockings are used to promote venous return and prevent edema, not for measuring blood pressure.
C. A thermometer measures body temperature and does not provide information on blood pressure or orthostatic changes.
D. A blood pressure cuff is essential for assessing orthostatic hypotension. The nurse will measure blood pressure while the patient is supine, sitting, and standing to determine any significant changes that occur with position changes.