Nokea
Nurse contributing to a care plan for a client being admitted to a facility with suspected pertussis. Which should the nurse include in the care plan? (Select all that apply.)
- A. Place client in a room with negative air pressure of at least 6 exchanges per hour
- B. Wear mask when providing care within 3 ft of client
- C. Place mask on client if transportation to another department is unavoidable
- D. Use sterile gloves when handling soiled linens
- E. Wear gown when performing care that may result in contamination from secretions
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Wearing a mask within 3 ft of the client helps prevent the spread of pertussis, which is transmitted through respiratory secretions.
C: Placing a mask on the client during transportation reduces the risk of spreading the infection to others.
E: Wearing a gown during care that may result in contamination from secretions further prevents transmission.
A: Negative air pressure is not necessary for pertussis transmission control.
D: Sterile gloves are not required for handling soiled linens in pertussis cases.
In summary, the correct answers focus on preventing the spread of pertussis through respiratory secretions, while the incorrect choices are not directly related to infection control measures for this condition.
You may also like to solve these questions
During evaluation, nurse must gather info about the client to...
- A. identify whether client outcomes have been met
- B. organize resources to proceed with implementing interventions
- C. establish client-centered, measurable & realistic outcomes
- D. determine priority of care & appropriate interventions
Correct Answer: A
Rationale: The correct answer is A because during evaluation, nurses must gather information about the client to identify whether client outcomes have been met. This step is crucial in determining the effectiveness of the care provided and if the client's needs have been addressed. Gathering this information helps in assessing the success of the interventions implemented.
Choice B is incorrect as organizing resources is part of the planning phase, not evaluation. Choice C is incorrect because establishing client-centered outcomes is part of the planning phase, not evaluation. Choice D is incorrect as determining priority of care and appropriate interventions is typically done during the assessment and planning phases, not evaluation.
Nurse is preparing in-service program about delegation. Which of following elements should she identify when presenting 5 rights of delegation? (Select all that apply.)
- A. Right client
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. Right supervision/evaluation ensures appropriate oversight, right direction/communication is crucial for clear instructions, and right circumstances involve assessing if it is appropriate to delegate the task. Right client is not directly related to delegation, and right time is not one of the traditional 5 rights of delegation.
Nurse caring for a client who reports severe sore throat, pain with swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The correct answer is D: Illness. In this stage, the client exhibits specific signs and symptoms of infection, such as severe sore throat, pain with swallowing, and swollen lymph nodes. This indicates active replication of the pathogen and the body's immune response. Other choices are incorrect because: A: Prodromal is the initial stage with vague, non-specific symptoms. B: Incubation is the period between exposure to the pathogen and the onset of symptoms. C: Convalescence is the recovery stage after the illness.
Nurse reviewing nutrition guidelines with parents of 11 yo. Which parent statement should indicate to nurse that they understand guidelines for school-age children?
- A. She wants to eat as much as us, but we're afraid she'll be overweight.
- B. She skips lunch sometimes but we figure it's okay as long as she has healthy breakfast & dinner.
- C. We limit fast food restaurant meals to 3x/week now
- D. We reward her school achievements with point system instead of pizza or ice cream
Correct Answer: D
Rationale: The correct answer is D because the parent's statement indicates an understanding of proper nutrition guidelines for school-age children. By rewarding school achievements with a point system instead of unhealthy foods like pizza or ice cream, the parent is promoting a positive relationship with food and reinforcing healthy eating habits. This approach encourages the child to focus on their achievements rather than using food as a reward, which aligns with recommended nutrition guidelines for school-age children.
Option A is incorrect as it focuses on weight concerns rather than nutrition guidelines. Option B is incorrect as skipping lunch is not a recommended practice for children's nutrition. Option C is incorrect as limiting fast food intake is a good practice, but it does not directly relate to understanding nutrition guidelines.
A home health nurse is discussing dangers of carbon monoxide poisoning with client. Which of following info should nurse include in her counseling?
- A. Carbon monoxide has distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with Hgb in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with Hgb in the body. Carbon monoxide is a colorless and odorless gas, so it does not have a distinct odor (choice A). Water heaters should be inspected annually, not every 5 years (choice B). Carbon monoxide poisoning affects the blood's ability to carry oxygen, not the lungs directly (choice C). By binding with hemoglobin, carbon monoxide reduces the blood's oxygen-carrying capacity, leading to tissue hypoxia and potentially fatal consequences. Therefore, it is crucial for the nurse to emphasize this information during counseling to help the client understand the serious implications of carbon monoxide exposure.