Nokea
The nurse has attended a staff education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed
- A. Placing a client with Cryptococcosis pneumonia on standard precautions.
- B. Wearing a particulate respirator mask (N95) when caring for a client with pharyngeal diphtheria.
- C. Removing alcohol-based hand rubs from a client's room who has mononucleosis.
- D. Placing a client who is incontinent of stool with Hepatitis A on contact precautions.
- E. Instructing a client with latent pulmonary tuberculosis to wear a surgical mask while in the hallway.
Correct Answer: A,D
Rationale: Cryptococcosis requires standard precautions, and Hepatitis A with incontinence requires contact precautions due to fecal-oral transmission. N95 is needed for TB, not diphtheria; hand rubs are safe for mononucleosis; latent TB does not require masking.
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The nurse is caring for a child admitted with varicella (chickenpox). Which of the following actions should the nurse take?
- A. Have a designated blood pressure cuff in the client's room.
- B. Remove all gowns and gloves after exiting the client's room.
- C. Clean commonly touched surfaces with warm, soapy water.
- D. Wear a protective gown when transporting the client to other departments.
Correct Answer: A,B
Rationale: A designated BP cuff and removing PPE after exiting prevent varicella spread (airborne and contact). Soapy water is insufficient, and gowns during transport are unnecessary if precautions are followed.
The nurse is assessing a client's peripheral vascular access device. The assessment shows that the site is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Which of the following complications is the client experiencing?
- A. Occlusion
- B. Infiltration
- C. Phlebitis
- D. Air embolism
Correct Answer: C
Rationale: Redness, warmth, pain, and edema indicate phlebitis, vein inflammation. Occlusion blocks flow, infiltration involves fluid leakage, and air embolism is unrelated.
The nurse is interviewing an older adult who reports a disturbed sleep pattern. The client states that he lies in bed tossing and turning and cannot fall asleep. The nurse should recommend that the client
- A. Stay in bed until he falls asleep but change positions more frequently.
- B. Take more naps earlier in the day that do not exceed one hour.
- C. Eat a meal high in carbohydrates to promote sleep.
- D. Reduce your time in bed if unable to fall asleep after 20 minutes.
Correct Answer: D
Rationale: Leaving bed after 20 minutes prevents associating bed with sleeplessness, a sleep hygiene principle. Staying in bed, napping, or high-carb meals disrupt sleep patterns.
The following scenario applies to the next 1 items
The nurse cares for a client on the oncology floor
Item 1 of 1
Admission Note
Physician Orders
The client was admitted for observation after reporting increasing fatigue, dyspnea, malaise, and a fever of 102°F (38.8°C). The client is currently being treated with doxorubicin for uterine sarcoma. The initial diagnostic testing revealed pneumonia and neutropenia.
The nurse recognizes that this client is at increased risk for developing ………………… therefore, the nurse should implement neutropenic precautions which involves …………………. Considering the client has a fever, the nurse anticipates an order for ……………
- A. systemic infection
- B. chronic renal failure
- C. washing hands frequently.
- D. wearing sterile gloves for client care.
- E. performing frequent oral care.
- F. 24-hour urine collection.
- G. collecting blood cultures.
Correct Answer: A,C,G
Rationale: Neutropenia increases systemic infection risk, requiring frequent handwashing and blood cultures for fever evaluation.
Room Number Patient and Diagnosis
43-year-old male receiving intravenous antibiotics for Lyme disease
Contact
17 -year-old female receiving antiviral for varicella.
Airborne and Contact
3
89-year-old male diagnosed with Mumps.
Droplet
4
33-year-old male newly diagnosed with human immunodeficiency virus (HIV).
Standard
The infection control nurse is reviewing client room assignments. Which room assignment requires modification? Room Number Patient and Diagnosis: 1. 43-year-old male receiving intravenous antibiotics for Lyme disease - Contact; 2. 17-year-old female receiving antiviral for varicella - Airborne and Contact; 3. 89-year-old male diagnosed with Mumps - Droplet; 4. 33-year-old male newly diagnosed with human immunodeficiency virus (HIV) - Standard
- A. Room 1
- B. Room 2
- C. Room 3
- D. Room 4
Correct Answer: A
Rationale: Lyme disease is not typically transmitted person-to-person and does not require contact precautions; standard precautions are sufficient. Varicella requires airborne and contact precautions, mumps requires droplet precautions, and HIV requires standard precautions, making Room 1's assignment incorrect.