Nokea
The client is admitted with a diagnosis of bacterial meningitis. Which precaution should the nurse implement?
- A. Standard precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: B
Rationale: Bacterial meningitis (e.g., Neisseria meningitidis) is transmitted via respiratory droplets, requiring droplet precautions. Standard, contact, and airborne precautions are not appropriate.
You may also like to solve these questions
The nurse is teaching the client with hepatitis B regarding transmission. The nurse should instruct the client to do which of the following?
- A. Refrain from eating fresh fruits and vegetables.
- B. Avoid using another family member's toothbrush.
- C. Clean the commode after each bowel movement.
- D. Boil water prior to drinking and place open containers in the refrigerator.
- E. Inform the dentist of his diagnosis.
Correct Answer: B, E
Rationale: Hepatitis B is transmitted via blood and bodily fluids. Avoiding sharing toothbrushes (B) prevents transmission through saliva or blood. Informing the dentist (E) ensures precautions during procedures. Eating fresh produce (A), cleaning the commode (C), and boiling water (D) are unrelated to hepatitis B transmission.
When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?
- A. A large gush of clear fluid from the vagina
- B. Systolic hypertension
- C. Abdominal rigidity
- D. Increased fetal movements
Correct Answer: C
Rationale: In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness, indicating a serious complication.
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
- A. Apply ice packs to both legs.
- B. Begin débridement by removing all charred clothing from wound.
- C. Apply Silvadene cream (silver sulfadiazine).
- D. Immerse both legs in cool water.
Correct Answer: D
Rationale: Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.
A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:
- A. Give the child 15 mL of syrup of ipecac.
- B. Give the child 10 mL of syrup of ipecac with a sip of water.
- C. Give the child 1 cup of water to induce vomiting.
- D. Bring the child to the ER immediately.
Correct Answer: D
Rationale: Before giving any emetic, the substance ingested must be known. At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. Vomiting should never be induced in an unconscious client because of the risk of aspiration.
The nurse has been assigned a client who delivered a 6-lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
- A. Length of her labor
- B. Type of episiotomy
- C. Amount of IV fluid to be infused
- D. Character of the fundus
Correct Answer: D
Rationale: The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourth stage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.