Nokea
The nurse is discussing infection control with a group of nursing students. Which conditions would it be correct to state droplet precautions are used for? Select all that apply.
- A. Influenza
- B. Viral meningitis
- C. Pertussis
- D. Hepatitis C
- E. Lyme disease
Correct Answer: A,C
Rationale: Influenza and pertussis require droplet precautions due to respiratory transmission. Viral meningitis, hepatitis C, and Lyme disease do not.
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The nurse is caring for a client who reports abdominal pain. When performing an abdominal assessment, the nurse should
- A. Auscultate for bowel sounds after inspecting the abdomen.
- B. Palpate the area where the client identifies pain prior to palpating other areas.
- C. Palpate to detect fluid, air, and fluid-filled or solid masses.
- D. Percuss for masses, tenderness, organ enlargement, and ascites.
Correct Answer: A
Rationale: Abdominal assessment follows the order: inspect, auscultate, percuss, palpate. Auscultation after inspection prevents altering bowel sounds. Palpating painful areas first or focusing only on palpation/percussion is incorrect.
The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 1030 . What action should the nurse take?
- A. Assess the surgical wound
- B. Collect blood cultures
- C. Administer oxygen at 2 L/minute
- D. Encourage by-mouth (PO) fluids
Correct Answer: C
Rationale: Changes in vital signs post-surgery may indicate respiratory or circulatory compromise. Administering oxygen at 2 L/minute is a prudent initial action to support oxygenation while further assessment occurs. Wound assessment, blood cultures, or fluids require specific clinical indications.
The nurse in the emergency department is preparing to receive a client exposed to inhalation anthrax. The nurse recognizes that this client requires
- A. Droplet precautions.
- B. Airborne precautions.
- C. Standard precautions.
- D. Contact precautions.
Correct Answer: C
Rationale: Inhalation anthrax is not transmissible person-to-person, requiring only standard precautions. Droplet, airborne, or contact precautions are unnecessary.
The nurse is performing a health assessment on a client. While performing percussion, which percussion sound would require follow-up?
- A. Dull tone over the spleen
- B. Hyperresonance over an adult's lung tissue
- C. Flat tone over bone
- D. Hyperresonance over a child's lung tissue
Correct Answer: B
Rationale: Hyperresonance in adult lungs suggests pneumothorax or emphysema, requiring follow-up. Dullness over spleen, flatness over bone, and hyperresonance in children are normal.
The nurse cares for a client and receives a phone call from the laboratory department regarding a critical sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Implement seizure precautions
- C. Read back the result for verification
- D. Recollect the laboratory specimen
Correct Answer: C
Rationale: Reading back the critical result verifies accuracy, the first step before further action. Notifying the provider, seizure precautions, or recollecting follow verification.