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The nurse in the medical-surgical unit is preparing the room for a client being admitted with varicella-zoster (chickenpox). Which of the following infection control precautions should the nurse implement?
- A. Place a surgical mask on the client during transport out of the client's room
- B. Remove all alcohol-based hand rubs from the room
- C. Wear a face shield while providing care
- D. Asking the client to put on a clean mask each time someone enters the room
Correct Answer: A
Rationale: Varicella requires airborne and contact precautions, including a mask on the client during transport.
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The nurse prepares to insert a peripheral vascular access device (PVAD) in the client's cephalic vein. The nurse plans to align the catheter how many degrees above the targeted vein?
- A. 10-30 degrees
- B. 30-45 degrees
- C. 45-90 degrees
- D. 45-60 degrees
Correct Answer: A
Rationale: A 10-30 degree angle is optimal for PVAD insertion to enter the vein without piercing through it. Higher angles increase the risk of vein perforation or improper placement.
The nurse is caring for an older adult receiving prescribed antibiotics for an infection. The client reports frequent watery stools that are foul-smelling. To prevent the spread of any potential secondary infection, the nurse should
- A. Place the client on contact (enteric) precautions.
- B. Place a surgical mask on the client during transport.
- C. Place face shields outside of the client's room.
- D. Keep the door to the client's room closed.
Correct Answer: A
Rationale: Foul-smelling, watery stools suggest possible Clostridium difficile, requiring contact (enteric) precautions to prevent spread. Masks, face shields, and closed doors are not specific to enteric infections.
The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client
- A. Trendelenburg
- B. Side-lying
- C. high-Fowler's
- D. Reverse Trendelenburg
Correct Answer: C
Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.
A client with a history of falls is admitted to the medical-surgical unit. The nurse should plan to implement which intervention to reduce this client's risk of falling?
- A. Encouraging the client to ambulate independently to improve muscle strength.
- B. Verify that the bed alarm is enabled during client rounding.
- C. Implementing a fall risk assessment every two days
- D. Implementing a restrictive mobility policy to minimize the potential of falls.
Correct Answer: B
Rationale: Verifying the bed alarm ensures immediate notification of movement, reducing fall risk for a client with a fall history.
The nurse is performing a health assessment on a client. While performing percussion, which percussion sound would require follow-up?
- A. Dull tone over the spleen
- B. Hyperresonance over an adult's lung tissue
- C. Flat tone over bone
- D. Hyperresonance over a child's lung tissue
Correct Answer: B
Rationale: Hyperresonance in adult lungs suggests pneumothorax or emphysema, requiring follow-up. Dullness over spleen, flatness over bone, and hyperresonance in children are normal.