Nokea
The nurse is caring for a client with human immunodeficiency virus (HIV). It would be appropriate for the nurse to assign the client to a room with the client diagnosed with
- A. Infectious mononucleosis.
- B. Mycoplasma pneumonia.
- C. Gastroenteritis (rotavirus).
- D. Mumps (infectious parotitis).
Correct Answer: A
Rationale: HIV is not airborne or droplet-transmitted, so rooming with a client with mononucleosis (non-respiratory transmission) is safe. Mycoplasma, rotavirus, and mumps require specific precautions.
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The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic?
- A. How to obtain the HCV vaccine
- B. How to dispose of sharps safely
- C. How to dispose of urine and feces for those with HCV
- D. Isolation precautions for individuals with HCV
Correct Answer: B
Rationale: Safe sharps disposal prevents needlestick injuries, a primary transmission route for HCV. No vaccine exists, and urine/feces disposal or isolation are less relevant.
The charge nurse is performing safety rounds on clients in the nursing unit. Which observation by the charge nurse requires follow-up? A client with
- A. An indwelling urinary catheter bag secured to the bed frame.
- B. Delirium tremens having a peripheral vascular access device (VAD) inserted.
- C. Right-sided weakness with their cane on the left side of the bed.
- D. A belt restraint was applied and secured over the chest.
Correct Answer: C,D
Rationale: A cane on the left side for right-sided weakness is inaccessible, and a belt restraint over the chest is unsafe, risking respiratory compromise. Catheter bag placement and VAD in delirium tremens are appropriate.
The nurse is caring for a child with varicella zoster. The nurse should implement which transmission-based precautions?
- A. Droplet precautions
- B. Airborne and contact precautions
- C. Contact and droplet precautions
- D. Contact precautions
Correct Answer: B
Rationale: Varicella zoster requires airborne and contact precautions due to its transmission via respiratory droplets and direct contact. Other options are insufficient.
The nurse is planning to perform a dressing change for a client with a stage three pressure injury. The nurse should initially perform which action?
- A. Gather all the necessary equipment
- B. Use non-sterile gloves to remove the old dressing
- C. Document the characteristics of the wound
- D. Administer prescribed oral pain medication
Correct Answer: A
Rationale: Gathering equipment ensures efficiency and sterility. Non-sterile gloves, documentation, and pain medication follow preparation.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.