Nokea
The nurse is caring for a client who has rubella. To prevent the spread of infection, which transmission-based precaution should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: B
Rationale: Rubella requires droplet precautions due to respiratory transmission.
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The nurse is supervising a student assisting a client with their newly prescribed crutches. Which action by the student requires follow-up by the nurse? The student
- A. Positions the handgrips so that the axillae support the client's body weight.
- B. Demonstrates the proper crutch stance at 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot.
- C. Observes two to three finger widths between the crutch pad and the client's axilla.
- D. Instructs the client to dry crutch tips with a paper towel if they become wet.
Correct Answer: A
Rationale: Axillary weight-bearing risks nerve damage; weight should be on hands. Proper stance, axilla gap, and drying tips are correct.
The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications?
- A. The development of an infection
- B. Hemorrhage
- C. Wound dehiscence
- D. Hematoma
Correct Answer: B
Rationale: Tachycardia with low blood pressure suggests hemorrhage, a life-threatening complication requiring immediate attention. Infection, dehiscence, and hematoma are less acute.
The nurse is providing preoperative teaching to a client scheduled for a pneumonectomy. Which of the following statements should the nurse make to the client?
- A. You must lay on your nonoperative side immediately following this surgery
- B. You can expect your lung function to return to normal within two to six hours
- C. You will want to avoid coughing after this surgery as you will be suctioned using a catheter
- D. You will be encouraged to get up and walk the same day as your surgery
Correct Answer: D
Rationale: Early ambulation post-pneumonectomy promotes lung expansion, prevents complications like pneumonia, and aids recovery. Lying on the nonoperative side is not universally required, lung function does not return to normal in hours, and coughing is encouraged to clear secretions, not avoided.
The nurse is preparing to administer intravenous chemotherapy to a client with cancer. While preparing the infusion in the client's room, the bag rips and leaks on the floor. The nurse should initially?
- A. obtain a chemotherapy spill kit.
- B. evacuate the client from the area.
- C. complete an incident report.
- D. request guidance from the pharmacy.
Correct Answer: A
Rationale: A chemotherapy spill kit is the initial action to safely clean hazardous material.
The nurse has attended a continuing education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed
- A. wearing gloves when obtaining vital signs.
- B. cohorting two clients with influenza in the same room.
- C. wearing a surgical mask when caring for a client with suspected rabies.
- D. initiating droplet precautions for a client with viral pneumonia.
Correct Answer: B,D
Rationale: Cohorting influenza clients and initiating droplet precautions for viral pneumonia align with infection control guidelines. Gloves for vital signs and a mask for rabies are not standard.