Nokea
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with droplet precautions? Select all that apply.
- A. Clostridium difficile
- B. Cryptococcal meningitis
- C. Mycoplasma pneumonia
- D. Haemophilus influenzae, type b pneumonia
- E. Rheumatic fever
- F. Varicella Zoster
- G. Scabies
Correct Answer: C,D
Rationale: Mycoplasma pneumonia and Haemophilus influenzae pneumonia require droplet precautions. Others require contact or standard precautions.
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The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their
- A. Dairy intake.
- B. Fiber intake.
- C. Fat intake.
- D. Calcium intake.
Correct Answer: B
Rationale: Fiber regulates bowel function in IBS. Dairy and fat may worsen symptoms, and calcium is unrelated to IBS management.
The infection control nurse reviews guidelines with other nurses. Which of the following statements by the nurses would indicate a correct understanding of the teaching?
- A. The nurse should wear a surgical mask when transporting a client with active pulmonary tuberculosis (TB).
- B. Disposable utensils must be provided for a client infected with hepatitis B.
- C. A surgical mask should be worn when working within three feet of the client infected with Neisseria meningitidis.
- D. A surgical gown should be applied when entering a client's room with bacterial pneumonia.
Correct Answer: C
Rationale: Neisseria meningitidis requires droplet precautions, including a surgical mask within 3 feet. TB requires an N95 mask, hepatitis B does not need disposable utensils, and bacterial pneumonia requires standard precautions.
You are educating a mother about the association between autism and the MMR vaccine. You know that the mother understands your instructions when she says:
- A. My child should not get the vaccine since it is known to cause autism.
- B. My child should get the individual immunizations for measles, mumps, and rubella since the individual vaccines do not cause autism.
- C. My child should get the MMR immunization since there is no evidence that it causes autism.
- D. My child should not get the immunization because it contains mercury.
Correct Answer: C
Rationale: Extensive research shows no link between MMR and autism, and MMR does not contain mercury. Individual vaccines are not standard, and avoiding vaccination is unsafe.
The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is reviewing the vital signs of a client admitted with atrial fibrillation. The client's vital signs are: T 37.5°C (99.6°F), P 88 and irregular, RR 20, BP 90/56 mmHg, pulse oximetry reading 96% on room air. The nurse should immediately address which vital sign?
- A. Temperature
- B. Blood pressure
- C. Respiratory rate
- D. Pulse
Correct Answer: B
Rationale: Low BP (90/56 mmHg) indicates potential hemodynamic instability, requiring immediate attention in atrial fibrillation. Temperature, respiratory rate, and pulse are less critical.