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The nurse is visiting the home of a client with Clostridium difficile. Which infection control measure should the nurse include?
- A. Ask the client to wear a surgical mask during the visit.
- B. Obtain vital signs with a disposable blood pressure cuff.
- C. Interview the client while maintaining 3 feet distance.
- D. Use sterile gloves when performing venipuncture.
Correct Answer: B
Rationale: Using a disposable blood pressure cuff prevents the spread of Clostridium difficile spores, which can persist on surfaces.
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A client is upset because they just found out that they have syphilis. The client tells the nurse, 'This is so upsetting! Does everyone need to know?' Which of the following responses, if made by the nurse, is the most therapeutic?
- A. We need to report this diagnosis to the local public health department, and they will contact your past partners.
- B. According to the Health Insurance Portability and Accountability Act (HIPAA), I can't tell anyone without your permission.
- C. You really should contact your sexual partners so they can be treated too.
- D. I understand you're upset. I'll stay here with you so that you can talk about it.
Correct Answer: A
Rationale: Reporting syphilis to the public health department is required for contact tracing, and this response addresses the client's concern while explaining the process.
The nurse teaches individuals about the human immunodeficiency virus (HIV) at a health fair. It would be correct for the nurse to state which of the following would indicate the need for HIV testing? Select all that apply.
- A. Pregnancy
- B. Engaged in sex work
- C. Have a sexually transmitted infection
- D. The use of injection drugs
- E. Men who have sex with men (MSM)
Correct Answer: A,B,C,D,E
Rationale: Pregnancy, sex work, STIs, injection drug use, and MSM are all risk factors warranting HIV testing to ensure early detection and treatment.
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.
Which of the following clients, receiving normal saline via IV infusion, is at the highest risk for bloodstream infections?
- A. A client who has a midline IV catheter in the left antecubital fossa.
- B. A client with a peripherally inserted central catheter (PICC) line in the right upper arm.
- C. A client with an implanted port in the right subclavian vein.
- D. A client who has a non-tunneled central line in the left internal jugular vein.
Correct Answer: D
Rationale: Non-tunneled central lines, such as those in the internal jugular vein, carry the highest risk of bloodstream infections due to their direct access to central circulation and external exposure.
The nurse is counseling a female client newly diagnosed with herpes simplex virus in the genitals. Which symptoms should the nurse educate the client to expect before an outbreak? Select all that apply.
- A. Lymphadenopathy
- B. Vaginal discharge
- C. Paresthesia
- D. Dysmenorrhea
- E. Malaise
Correct Answer: A,C,E
Rationale: Lymphadenopathy, paresthesia, and malaise are prodromal symptoms of genital herpes outbreaks, indicating viral reactivation.