Author Question: Before entering the room of a client on isolation where all protective barriers are required, the ... (Read 106 times)

Metfan725 · **on:** Jul 24, 2018

Before entering the room of a client on isolation where all protective barriers are required, the nurse first puts on the:

A. Gown
B. Gloves
C. Eyewear
D. Mask/respirator

Question 2

When differentiating a client's adverse reaction to a blood transfusion, a nurse evaluates an anaphylactic response by the presence of:

A. Wheezing and chest pain
B. Headache and muscle pain
C. Hypotension and tingling of the extremities
D. Crackles in the lungs and increased central venous pressure

frogdreck123456 · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

D
D. Prepare for entrance into isolation room. Apply either surgical mask or a fitted respirator around mouth and nose.
A. Apply gown, being sure it covers all outer garments. Pull sleeves down to wrist. Tie securely at neck and waist.
B. Apply disposable gloves. If gloves are worn with gown, bring glove cuffs over edge of gown sleeves.
C. Apply eyewear or goggles snugly around face and eyes.

Answer to Question 2

A
A. Observe the client for wheezing, chest pain, and possible cardiac arrest. These are all indications of an anaphylactic reaction.
B. Be alert to client complaints of headache or muscle pain in the presence of a fever. Both may be indicative of a febrile nonhemolytic reaction.
C. In clients receiving massive transfusions, observe client for mild hypothermia, cardiac dysrhythmias, hypotension, and hypocalcemia. Cold blood products can affect the cardiac conduction system, resulting in ventricular dysrhythmias. Other cardiac dysrhythmias, hypotension, and tingling may indicate hypocalcemia, which occurs when citrate (used as a preservative for some blood products) combines with client's calcium.
D. Crackles in bases of lungs and a rising central venous pressure (CVP) are indications of circulatory overload.