Nokea
The nurse is educating staff on infection control. Which of the following statements by the nurse would indicate a correct understanding of infection control guidelines for influenza? Select all that apply.
- A. Limiting visitation to 30 minutes per day.
- B. Keeping the door to the client's room closed.
- C. Wearing a surgical mask when providing care.
- D. Placing the client in a room at the end of the hall.
- E. Cleaning common surfaces with 70% isopropyl alcohol.
Correct Answer: B,C
Rationale: Influenza requires droplet precautions, including a surgical mask within 3 feet and a closed door to reduce transmission. The other options are not standard for influenza.
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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.
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing
--------------based on the client’s------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
Following scheduled radioactive iodine therapy in a nuclear medicine department, a nurse is speaking with a client following the client's ingestion of radioactive iodine regarding strategies to avoid radiating the client's family members. The nurse recognizes the need for additional client teaching when the client states:
- A. I understand the need to avoid sharing food or utensils with others.
- B. My children will miss my hugs and kisses for the next week.
- C. I'll travel for a couple of weeks to prevent my family from receiving radiation from me.
- D. I understand the need to flush the toilet with the lid closed two to three times after each use.
Correct Answer: C
Rationale: Traveling for weeks is excessive and unnecessary. Avoiding shared items, limiting close contact, and double flushing are appropriate to reduce radiation exposure.
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.