Nokea
The nurse is preparing to provide care for a client with disseminated herpes zoster. The nurse plans to don which personal protective equipment (PPE)? Select all that apply.
- A. Goggles
- B. Gown
- C. Gloves
- D. Shoe covers
- E. N95 respirator
- F. Surgical face mask
Correct Answer: B,C,E
Rationale: Disseminated herpes zoster requires airborne and contact precautions, necessitating a gown, gloves, and N95 respirator. Goggles, shoe covers, and surgical masks are insufficient.
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The nurse is planning care for a client diagnosed with Mycoplasma pneumonia. The nurse should plan to
- A. place the client in a private room with negative airflow.
- B. wear a surgical mask within 3 feet of the client.
- C. wear gloves when in contact with the client.
- D. provide disposable meal trays and utensils.
Correct Answer: B
Rationale: Mycoplasma pneumonia requires droplet precautions, including a surgical mask within 3 feet. Negative airflow, gloves, and disposable trays are not required.
The nurse is caring for a client with the following clinical data. Based on the clinical data, the nurse should clarify which order with the primary healthcare provider (PHCP)
- A. Urine analysis (UA)
- B. Head CT Scan
- C. Regular diet
- D. Ammonia level
Correct Answer: C
Rationale: A regular diet prescription should be questioned because of the client's medical history of diabetes mellitus and hypertension. The appropriate diet would be one restricted in carbohydrates and sodium. Thus, the nurse should follow up with the PHCP regarding this order.
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.
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 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.