Nokea
The nurse is observing infection control practices in the nursing unit. Which of the following findings require follow-up? A client with
- A. H. pylori placed on standard precautions.
- B. rotavirus provided a disposable blood pressure cuff.
- C. rubella and their door is kept closed at all times.
- D. influenza ambulating in the hall with a surgical mask.
- E. Legionnaires' disease placed on contact precautions.
Correct Answer: A,E
Rationale: H. pylori requires contact precautions due to fecal-oral transmission, and Legionnaires' disease requires standard precautions, not contact.
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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.
The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply.
- A. Place a small pillow between the client's knees.
- B. Places the client's arms at their side.
- C. Fanfold a drawsheet along the backside of the client.
- D. Instruct the client to laterally flex the neck during the turn.
- E. Roll the client as one unit in a smooth, continuous motion.
Correct Answer: A,B,C,E
Rationale: Pillow placement, arms at sides, drawsheet use, and rolling as a unit maintain spinal alignment. Neck flexion risks injury during log rolling.
The nurse is performing community health screenings. A client tells the nurse that they smoke two packs a day of cigarettes and they have smoked for the past six years. How should the nurse document the Pack-years this client has smoked?
- A. 3.5 pack years
- B. 3 pack years
- C. 12 pack years
- D. 6 pack years
Correct Answer: C
Rationale: Pack-years = packs per day × years smoked = 2 × 6 = 12 pack-years. Other calculations are incorrect.
The nurse is assisting a client with the use of a fracture bedpan. Which action should the nurse take?
- A. Position the client prone while placing the bedpan.
- B. Raise the head of the bed to 30 degrees.
- C. Place the open rim of the bedpan toward the head of the bed.
- D. Lower all of the side rails
Correct Answer: B
Rationale: Raising the head of the bed to 30 degrees facilitates client comfort and proper positioning for a fracture bedpan. Prone positioning is incorrect, the open rim faces the foot of the bed, and lowering all side rails is unsafe.
The nurse is preparing to obtain a wound culture on an infected leg ulcer. Before swabbing the wound to obtain the culture, the nurse should
- A. Clean the wound with sterile saline.
- B. Pat dry the wound with gauze.
- C. Irrigate the wound with hydrogen peroxide.
- D. Don sterile gloves
Correct Answer: A
Rationale: Cleaning with sterile saline removes debris, ensuring an accurate culture. Drying, using peroxide, or sterile gloves (clean gloves suffice) are not appropriate.