Nokea
A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control. Play time, parent instruction, and room assignment are secondary.
You may also like to solve these questions
The home health aide caring for a home bound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Teach the client about foods high in fiber.
- C. Administer a prescribed dose of a laxative.
- D. Assist the client in drinking warm prune juice.
Correct Answer: D
Rationale: Assisting with drinking warm prune juice is within the aide's scope and promotes natural relief of constipation. Listening for bowel sounds, teaching about fiber, and administering laxatives require nursing skills and are beyond the aide's role.
The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?
- A. A client who had an abdominal-perineal resection 3 days ago has no drainage on the dressing and is reporting chills.
- B. A client who fell from a ladder and has a collapsed left lower lung with 100 mL drainage in a chest tube collection container.
- C. A client who was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm-sized dark red drainage.
- D. A client who is post-mastectomy 2 days ago and has 50 mL of serosanguineous fluid in a Jackson-Pratt drain.
Correct Answer: A
Rationale: The client with no drainage and chills may have an infection or sepsis, which are life-threatening complications requiring immediate assessment and physician notification. The chest tube drainage is normal, the gunshot wound drainage is not excessive, and the mastectomy drain output is expected, making these less urgent.
The smell of cigarette smoke is coming from a client's bathroom. Which action should the nurse implement first?
- A. Document the occurrence in the client's record.
- B. Obtain a prescription for a nicotine patch during hospitalization.
- C. Educate the client about the hospital smoking policy.
- D. Notify the charge nurse about the situation immediately.
Correct Answer: D
Rationale: Notifying the charge nurse ensures immediate enforcement of the no-smoking policy to prevent fire risks. Documenting, prescribing patches, or educating are secondary actions.
A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?
- A. Monitor for impending signs of shock.
- B. Initiate enteric precaution procedures.
- C. Reduce light, noise and temperature.
- D. Encourage electrolyte supplements.
Correct Answer: A
Rationale: Monitoring for signs of shock is critical due to the client's dehydration and fluid volume deficit, which could lead to organ failure. Enteric precautions, environmental adjustments, and electrolyte supplements are important but secondary to preventing life-threatening shock.
Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
- A. Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia.
- B. Heparin in Normal Saline prescribed for deep vein thrombosis.
- C. Magnesium in Normal Saline prescribed for hypomagnesemia.
- D. Regular insulin in Normal Saline prescribed for ketoacidosis.
Correct Answer: A
Rationale: Ceftriaxone can be safely administered by gravity infusion with nurse monitoring, as its dosing is less sensitive to minor flow rate variations. Heparin, magnesium, and insulin require precise infusion rates due to risks of bleeding, toxicity, or glucose imbalances, necessitating an IV pump.