Nokea
The nurse is discussing infection control with a group of nursing students. It would be correct to state that airborne precautions are used for which condition? Select all that apply.
- A. Pulmonary tuberculosis
- B. Pertussis
- C. Rubeola
- D. Hepatitis A
- E. Rubella
Correct Answer: A,C
Rationale: Pulmonary TB and rubeola (measles) require airborne precautions due to airborne transmission. Pertussis and rubella require droplet precautions, and Hepatitis A is contact-based.
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Which of the following actions is most effective at reducing the incidence of health-care-associated infections?
- A. Screen all newly admitted clients for colonization or infection with MRSA.
- B. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms.
- C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.
- D. Require nursing staff to wear gowns to change wound dressings for all clients.
Correct Answer: C
Rationale: Alcohol-based hand rub availability is the most effective way to reduce healthcare-associated infections by promoting frequent hand hygiene. MRSA screening, automatic antibiotics, and universal gown use are less effective or inappropriate.
The charge nurse is making room assignments for assigned clients. The charge nurse has one private room remaining, the nurse should assign the private room to the client admitted with
- A. Epilepsy, who had a tonic-clonic seizure two hours ago.
- B. An indwelling urinary catheter and has proteus mirabilis in the urine.
- C. Viral meningitis and has a fever.
- D. Clostridium difficile who is incontinent of stool.
Correct Answer: D
Rationale: C. difficile with incontinence requires contact precautions, necessitating a private room to prevent spread. Other conditions do not require isolation.
The nurse is caring for a client who is 24 hours postoperative following a left total knee replacement. Which assessment data would indicate that the client is ready for discharge?
- A. Pulse (P) 102, RR 18, BP 104/72 mm Hg
- B. Urine output of 200 mL in the past 8 hours
- C. Lung bases are clear upon auscultation
- D. The client rates left knee pain as 8/10 on the Numerical Rating Scale
Correct Answer: C
Rationale: Clear lung bases indicate no respiratory complications, such as pneumonia, which is critical for discharge readiness. A pulse of 102 and low blood pressure (104/72 mm Hg) suggest possible instability, requiring further evaluation. Low urine output (200 mL/8 hours) indicates potential renal issues, and severe pain (8/10) suggests inadequate pain control, both contraindicating discharge.
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.
The nurse is teaching a client who recently had a femoral vein central line catheter placed. Which of the following information should the nurse include?
- A. You will need to avoid drinking more than 500 mL per day.
- B. You will clean the site daily with soap and water.
- C. You should not sit up more than 45 degrees.
- D. You can remove the dressing if it becomes itchy.
Correct Answer: B
Rationale: Daily cleaning with soap and water maintains hygiene at the femoral central line site. Fluid restriction, angle limitation, and patient removal of dressings are incorrect and unsafe.