q. 26-30
A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?
A. Contact
B. Droplet
C. Protective
D. Airborne
D. Airborne
A nurse is reinforcing teaching with a group of assistive personnel (AP) about infection control measures on the unit. The nurse should remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?
A. Properly disposing of contaminated equipment
B. Discarding used syringes in appropriate containers
C. Changing soiled linens daily for clients with draining wounds
D. Performing hand hygiene frequently and consistently
D. Performing hand hygiene frequently and consistently
A nurse has completed morning care for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first?
A. N95 mask
B. Gloves
C. Gown
D. Goggles
B. Gloves
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client’s pulse. Which of the following items should the nurse wear?
A. Surgical mask
B. Sterile gloves
C. Clean gloves
D. Protective eyewear
C. Clean gloves
A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last?
A. N95 mask
B. Gloves
C. Gown
D. Goggles
A. N95 mask
A nurse is assisting with the admission of a client who requires droplet precautions due to pertussis. Which of the following isolation precautions should the nurse take while caring for this client?
A. Ensure that the client's room has negative airflow.
B. Wear a mask when giving the client care.
C. Ensure that the client's room has HEPA filtration.
D. Wear a gown when giving the client care.
B. Wear a mask when giving the client care.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
A. BUN
B. Potassium
C. RBC count
D. WBC count
D. WBC count
A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment is should the nurse wear when setting up the client’s meal tray?
A. Gloves
B. Goggles
C. Gown
D. Mask
D. Mask
A nurse is assisting with the admission of a client who has leukemia. Which of the following transmission-based precautions should the nurse implement?
A. Droplet
B. Contact
C. Airborne
D. Protective environment
D. Protective environment
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?
A. Take temperature once a day.
B. Wash the armpits and genitals with a gentle cleanser daily.
C. Change the litter boxes while wearing gloves.
D. Wash dishes in warm water.
A. Take temperature once a day.
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client?
A. Baked chicken
B. Bagels
C. A factory-sealed box of chocolates
D. Fresh fruit basket
D. Fresh fruit basket
A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza?
A. Individuals at high risk should receive the live influenza vaccine.
B. Immunization for influenza should be repeated every 10 years.
C. The composition of the influenza vaccine changes yearly.
D. The influenza vaccine is necessary only for clients who have never had influenza.
C. The composition of the influenza vaccine changes yearly.
A nurse observes an assistive personnel (AP) entering the room of a client who is under contact precautions without wearing personal protective equipment (PPE). Which of the following actions should the nurse take?
A. Give the AP the appropriate PPE.
B. Notify the charge nurse about the AP's lack of PPE.
C. Volunteer to provide an in-service about infection control.
D. Speak with the AP when she exits the room about the appropriate protocol.
A. Give the AP the appropriate PPE.
A nurse is reinforcing teaching with a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?
A. "If you wear gloves, disinfect the gloves after use."
B. "Make sure the clients wash their hands before they eat."
C. "Use an alcohol rub when your hands are visibly soiled."
D. "If you don’t have an infection, your hands won’t infect others."
B. "Make sure the clients wash their hands before they eat."
A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?
A. Tuberculin skin test
B. Sputum culture for acid fast bacillus (AFB)
C. Bacille Calmette-Guérin (bCG) vaccine
D. Chest x-ray
A. Tuberculin skin test
A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions?
A. Xerostomia
B. Gingivitis
C. Candidiasis
D. Halitosis
C. Candidiasis
A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?
A. Administer a saline enema for constipation.
B. Initiate contact precautions.
C. Encourage independence in the completion of ADLs.
D. Monitor oral mucosa daily.
D. Monitor oral mucosa daily.
A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain to the client that, after the laboratory has the enzyme immunoassay (EIA) results, it will use which of the following tests to
confirm the diagnosis?
A. CD4+ T-cell count
B. Western blot assay
C. Quantitative RNA assay
D. Viral load test
B. Western blot assay
A nurse is contributing to a teaching plan about the prevention of hepatitis A. The nurse should include that which of the following activities can spread hepatitis A?
A. Sharing personal hygiene items like razors.
B. Eating uncooked foods.
C. Getting a tattoo.
D. Having vaginal intercourse.
B. Eating uncooked foods.
A nurse is reinforcing discharge teaching with a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include in the teaching?
A. "Avoid using moisturizing lotions on your skin."
B. "Wash your hair with a mild shampoo."
C. "Apply powder liberally to sensitive areas of skin."
D. "Use a sun-blocking agent with a sun protection factor of 10."
B. "Wash your hair with a mild shampoo."
A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
A. Thickened skin
B. Spinal deformity
C. Iritis
D. Facial rash
D. Facial rash