Nokea
A healthcare professional is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the healthcare professional initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet. Droplet precautions are required for infections that spread via droplets larger than 5 microns in diameter, such as pharyngeal diphtheria. Contact precautions are used for diseases that spread by direct or indirect contact. Airborne precautions are for diseases that spread through small particles in the air. Protective precautions are not a standard precautionary measure for specific infections like pharyngeal diphtheria.
You may also like to solve these questions
When assessing a client's heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a:
- A. Pericardial friction rub
- B. Heart murmur
- C. S3 heart sound
- D. S4 heart sound
Correct Answer: A
Rationale: A pericardial friction rub is characterized by a scratching sound that occurs during both systole and diastole. It becomes more distinct when the client is sitting up and leaning forward. This indicates an inflammation of the pericardial sac rubbing against the layers of the heart. Heart murmurs (choice B) are abnormal heart sounds caused by turbulent blood flow, not by friction like in a pericardial rub. S3 and S4 heart sounds (choices C and D) are additional heart sounds related to abnormal ventricular filling, not to pericardial friction rubs.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions?
- A. Tossed salad with low-sodium dressing, bacon, and tomato sandwich.
- B. New England clam chowder, unsalted crackers, fresh fruit salad.
- C. Skim milk, turkey salad, roll, and vanilla ice cream.
- D. Macaroni and cheese, diet Coke, and a slice of cherry pie.
Correct Answer: C
Rationale: The correct answer is C: Skim milk, turkey salad, roll, and vanilla ice cream. These items are low in sodium, making it a suitable meal for someone on a low-sodium diet. Skim milk, turkey salad, and vanilla ice cream are naturally low in sodium, while the roll can be selected as a low-sodium option. Choices A, B, and D contain items that are typically high in sodium, such as bacon, clam chowder, crackers, and cheese, making them unsuitable for a low-sodium diet.
Which statement by the nurse indicates culturally responsive care for a client following Islamic practices?
- A. "I will make sure the menu includes halal options."
- B. "I will ask the client if they want to schedule prayer times during the day."
- C. "I will avoid discussing care when the client's family is around."
- D. "I will make sure daily communion is available for this client."
Correct Answer: B
Rationale: The correct answer is B. Asking the client if they want to schedule prayer times during the day demonstrates respect and consideration for Islamic practices. Providing halal options (choice A) is important for dietary requirements in Islam, but it may not address the client's spiritual needs. Avoiding discussing care in front of the client's family (choice C) is not directly linked to Islamic practices and may not necessarily enhance cultural responsiveness. Offering daily communion (choice D) is associated with Christian religious practices, not Islamic practices, and may not meet the client's religious needs.
A healthcare professional is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The healthcare professional should set the pump to deliver how many mL/hr?
- A. 107 mL/hr
- B. 75 mL/hr
- C. 90 mL/hr
- D. 60 mL/hr
Correct Answer: A
Rationale: To calculate the mL/hr rate for the infusion, divide the total volume (750 mL) by the total time (7 hours). 750 mL · 7 hours = 107 mL/hr. This means that the pump should be set to deliver approximately 107 mL/hr. Choice B (75 mL/hr) is incorrect because it does not reflect the correct calculation. Choice C (90 mL/hr) is incorrect as it does not align with the accurate calculation. Choice D (60 mL/hr) is incorrect as it does not match the correct mL/hr rate obtained through the calculation.
A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glascow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glascow Coma Scale 13, no ventilator required
Correct Answer: B
Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.