Nokea
The charge nurse is responding to an outbreak of influenza in a long-term care facility. To prevent the spread of this infection, the nurse recommends
- A. Having clients wear respirator masks (N95) while ambulating in the hallway.
- B. Placing air purifiers in the corridors.
- C. Obtaining prescriptions for antiviral medications for those infected.
- D. Isolating those infected using droplet precautions.
Correct Answer: C,D
Rationale: Antiviral medications and droplet precautions for infected clients control influenza spread. Client N95 masks and air purifiers are less effective.
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The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside?
- A. One liter of 0.9% saline
- B. Sterile gloves
- C. Portable ultrasound
- D. Suction equipment
Correct Answer: D
Rationale: Severe pre-eclampsia increases seizure risk (eclampsia), requiring suction equipment at the bedside to manage airway secretions during a seizure. Saline, gloves, and ultrasound are not immediate priorities for seizure management.
The charge nurse is making room assignments for assigned clients. The charge nurse has one private room remaining, the nurse should assign the private room to the client admitted with
- A. Epilepsy, who had a tonic-clonic seizure two hours ago.
- B. An indwelling urinary catheter and has proteus mirabilis in the urine.
- C. Viral meningitis and has a fever.
- D. Clostridium difficile who is incontinent of stool.
Correct Answer: D
Rationale: C. difficile with incontinence requires contact precautions, necessitating a private room to prevent spread. Other conditions do not require isolation.
The nurse is caring for a client who has pulmonary tuberculosis (TB). Which infection control measure should the nurse implement?
- A. Restrict visitors who are pregnant
- B. Remove any portable fans in the room
- C. Wear a dosimeter badge during client care
- D. Place the client further away from the nursing station
Correct Answer: B
Rationale: Portable fans can spread TB bacilli, so they should be removed. Pregnant visitors are not specifically restricted, dosimeters are for radiation, and room placement is less critical.
The nurse is discharging a client home who has pulmonary tuberculosis. To prevent disease transmission of the client's infection to others, the nurse should recommend that
- A. Common household surfaces get disinfected with a bleach solution.
- B. Your mouth should be covered with a tissue when you cough or laugh and dispose of it in a trash receptacle.
- C. Hand hygiene should be performed frequently with soap and water.
- D. Meals be served on disposable dishes and immediately discarded using gloves.
Correct Answer: B
Rationale: Covering the mouth during coughing or laughing prevents airborne TB transmission. Bleach disinfection, frequent hand hygiene, and disposable dishes are less specific to TB prevention.
The nurse is caring for a client with an indwelling urinary catheter connected to a drainage bag. The nurse demonstrates effective care when. Select all that apply.
- A. Emptying the drainage bag when it is half full.
- B. Collecting a urine specimen for culture from the port in drainage tubing.
- C. Clamping the urinary catheter tubing prior to discontinuation.
- D. Instructing the client to carry the collection bag above their bladder during ambulation.
- E. The tubing goes in and out of the urethra during cleaning.
Correct Answer: A,B
Rationale: Emptying when half full prevents reflux, and collecting from the port ensures sterility. Clamping is unnecessary, carrying above the bladder risks reflux, and tubing movement risks infection.