Nokea
The nurse is discharging a client home who has pulmonary tuberculosis. To prevent disease transmission of the client's infection to others, the nurse should recommend that
- A. Common household surfaces get disinfected with a bleach solution.
- B. Your mouth should be covered with a tissue when you cough or laugh and dispose of it in a trash receptacle.
- C. Hand hygiene should be performed frequently with soap and water.
- D. Meals be served on disposable dishes and immediately discarded using gloves.
Correct Answer: B
Rationale: Covering the mouth during coughing or laughing prevents airborne TB transmission. Bleach disinfection, frequent hand hygiene, and disposable dishes are less specific to TB prevention.
You may also like to solve these questions
The charge nurse is preparing for an influx of clients with measles (rubeola) in the emergency department. To prevent the spread of this infection, the nurse recommends
- A. The distribution of respirator masks (N95) to nursing staff.
- B. Disposable face shields outside client rooms.
- C. The placement of bleach wipes to disinfect commonly touched surfaces.
- D. The removal of alcohol-based hand rubs.
Correct Answer: A
Rationale: Measles requires airborne precautions, including N95 respirators for staff. Face shields, bleach wipes, and removing hand rubs are not specific to airborne transmission.
The nurse is teaching a client how to ambulate using a cane. Which action should the nurse take?
- A. Stand on the client's unaffected (stronger) side during ambulation
- B. Instruct the client to look down at their feet as they ambulate
- C. Instruct the client to move the weaker leg to the cane after placing the cane forward.
- D. Advance the cane 6-10 inches with each step
Correct Answer: A
Rationale: Standing on the stronger side provides support. Looking down risks falls, the stronger leg moves first, and advancement is 12-16 inches.
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.
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.
The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply.
- A. The client reports feeling nauseated.
- B. The client's lower extremities are swollen.
- C. The client expresses nervousness about test results.
- D. The client reports that their leg is itching.
- E. The client rates pain at a 6 on a scale of 1 to 10.
- F. The client vomits twice after eating dinner.
Correct Answer: A,C,D,E
Rationale: Subjective data are client-reported, like nausea, nervousness, itching, and pain rating. Swelling and vomiting are objective, observed by the nurse.