Nokea
The nurse is triaging a client who reports recent international travel. The primary healthcare provider (PHCP) suspects the client may have severe acute respiratory syndrome (SARS). The nurse should initially
- A. place the client on contact and airborne precautions.
- B. obtain blood, urine, and sputum for culture.
- C. prepare the client for a chest radiograph (x-ray).
- D. infuse 0.9 saline at 100mL/hr.
Correct Answer: A
Rationale: SARS requires contact and airborne precautions to prevent transmission due to its respiratory spread.
You may also like to solve these questions
The nurse is assessing a client for bacterial meningitis. Which of the following assessments should the nurse perform? Select all that apply.
- A. Oral temperature
- B. Patellar reflexes
- C. Weber and Rinne tests
- D. Glasgow Coma Scale
- E. Orthostatic blood pressure
Correct Answer: A,D
Rationale: Oral temperature assesses for fever, a key symptom of meningitis, and the Glasgow Coma Scale evaluates neurological status, critical for detecting meningitis-related changes.
The nurse is teaching a group of nursing students infectious diseases that are reportable to the local health department. Which of the following conditions should be reported? Select all that apply.
- A. Bacterial vaginosis
- B. Herpes simplex virus (HSV)
- C. Human immunodeficiency virus (HIV)
- D. Hepatitis A
- E. Syphilis
- F. Human Papilloma Virus infection (HPV)
Correct Answer: C,D,E
Rationale: HIV, Hepatitis A, and Syphilis are reportable to public health authorities due to their significant public health impact and potential for transmission.
The nurse is planning a community health course about the prevention of Lyme disease. Which of the following information should the nurse include?
- A. You should try limiting your outdoor activities between 10 a.m. and 4 p.m.
- B. Wear sunglasses that wrap around and block UVA and UVB rays.
- C. Wear long-sleeved clothing when in heavily wooded areas.
- D. Apply sunscreen with at least an SPF of 30.
Correct Answer: C
Rationale: Wearing long-sleeved clothing in wooded areas reduces skin exposure to ticks, which transmit Lyme disease.
The nurse is caring for a client with a central venous catheter (CVC). The nurse knows which of the following is a common symptom of Central Line-Associated Bloodstream Infections (CLABSI)?
- A. Diarrhea
- B. Fever and chills
- C. Productive cough
- D. Muscle spasms
Correct Answer: B
Rationale: Fever and chills are hallmark symptoms of CLABSI, indicating a systemic infection originating from the catheter site.
The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Note
Vital Signs
Client reports right elbow pain and swelling for three days. The client says that he scraped his elbow while rollerblading, and it has become painful and swollen for the past two days. He reports waking up with a fever of 101.3°F (38.5°C) and feeling lightheaded. On assessment, the client appeared lethargic and pale. The client has a full range of motion in the elbow but reports pain with movement. The client reports pain of '7' on a scale from 0-10. The elbow has erythema with a large red bump, swollen and hot to the touch. Clear lung fields bilaterally. S1/S2 heart tones. Normoactive bowel sounds. Denies nausea. History of asthma and seasonal
Allergies.
The nurse reports the assessment findings and vital signs to the primary healthcare provider (PHCP). Click to specify if the potential prescription is anticipated or contraindicated for this client.
- A. Obtain peripheral vascular access
- B. Administer albuterol via nebulizer
- C. Collect blood cultures
- D. Infuse hypertonic saline at 30 mL/kg
- E. Administer broad-spectrum antibiotics
- F. Collect serum lactic acid
Correct Answer: A: Anticipated, B: Contraindicated, C: Anticipated, D: Contraindicated, E: Anticipated, F: Anticipated
Rationale: A: Peripheral access is needed for diagnostics and treatment. B: Albuterol is not indicated without respiratory symptoms. C: Blood cultures identify the infection source. D: Hypertonic saline is inappropriate for this case. E: Broad-spectrum antibiotics treat suspected infection. F: Serum lactic acid assesses for sepsis.