Nokea
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.
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The nurse is assisting a client with the use of a fracture bedpan. Which action should the nurse take?
- A. Position the client prone while placing the bedpan.
- B. Raise the head of the bed to 30 degrees.
- C. Place the open rim of the bedpan toward the head of the bed.
- D. Lower all of the side rails
Correct Answer: B
Rationale: Raising the head of the bed to 30 degrees facilitates client comfort and proper positioning for a fracture bedpan. Prone positioning is incorrect, the open rim faces the foot of the bed, and lowering all side rails is unsafe.
A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client
- A. withdrawing from alcohol and is malnourished.
- B. receiving methylprednisolone for an asthma exacerbation.
- C. has an external urinary catheter device for urinary incontinence.
- D. receiving total parenteral nutrition (TPN) via a central line
Correct Answer: D
Rationale: TPN via a central line poses the highest infection risk due to the invasive device and nutrient-rich solution.
Health History
45-year-old female admitted for laparoscopic cholecystectomy. The client recently had a weight loss of ten kilograms through dieting, and cholelithiasis was subsequently discovered. The client is alert and oriented x 4. No known drug allergies. No surgical history. The client takes levothyroxine for hypothyroidism.
• Vital Signs
Oral temperature 97 F (36° C); Pulse 90 bpm; Respirations 18; BP 110/64 mm Hg; Oxygen saturation 96% on room air.
A nurse is caring for a client in a surgery center scheduled for laparoscopic cholecystectomy.Click to specify if the nursing intervention is completed during the preoperative, intraoperative, or postoperative phase. Each intervention may be completed in more than one phase. Each row must have at least one but may have more than one response option selected.
- A. Verify the client’s name and date of birth
- B. Verify the client’s nothing-by-mouth (NPO) status
- C. Administration of prophylactic antibiotic
- D. Obtaining laboratory work such as complete blood count, clotting studies, and pregnancy test
- E. Assessment of the surgical incision site for type and amount drainage
- F. Verifying that the informed consent has been completed
- G. Confirming the correct sponge and instrument count
Correct Answer:
Rationale:
The nurse is performing a physical assessment. When assessing a client's eyes for accommodation, which of the following actions would the nurse perform?
- A. Bring a penlight from the side of the client's face and briefly shine the light on the pupil.
- B. Ask the client to gaze at a distant object and then at a test object close to them.
- C. Obtain a tuning fork and place it in the middle of the client's forehead.
- D. Have the client stand twenty feet away from a Snellen chart.
Correct Answer: B
Rationale: Accommodation is tested by having the client shift gaze from a distant to a near object, observing pupil constriction and convergence. Penlight tests pupil response, tuning fork tests hearing, and Snellen tests vision.
The nurse is observing infection control practices in the nursing unit. Which of the following findings requires follow-up? Select all that apply.
- A. Doors kept closed for clients with contact precautions
- B. Gloves being worn by staff to pass meal trays
- C. Disposable dishes being used for clients on isolation precautions
- D. Bedside fan being removed from a room with negative pressure
- E. Alcohol-based hand sanitizers for a client with C. diff
Correct Answer: B,E
Rationale: Gloves are not required for passing meal trays unless direct contact with infectious material is anticipated. Alcohol-based sanitizers are ineffective against C. difficile; soap and water are required.