Chapter 16: NCLEX book questions

The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? 1. Private room or cohort client 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room

1. Meningtis is transmitted by droplet precautions for this disease. Include a private room or cohort client and use of a standard precaution mask.

The community health nurse is providing a teaching session about terrorism to members of the community and is discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted by which routes? Select all that apply. 1. Bites from ticks or deer flies 2. Inhalation of bacterial spores 3. Through a cute or abrasion in the skin 4. Direct contact with an infected individual 5. Sexual contact with an infected individual 6. Ingestion of contaminated undercooked meat

2, 3,6. Anthrax is caused by Bacillus anthracis, and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs.

The nurse is preparing to initiate an IV line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? 1. Initiate the IV line without use of a pump 2. Contact the electrical maintenance dept for assistance 3. Plug in the pump cord in the available plug above the room sink 4. Use an extension cord from the nurses's lunge for the pump plug

2. Electrical equipment must be maintained in good working order and should be grounded. The nurse needs to use hospital resources for assistance

The ED nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1. Prepare the triage rooms 2. Activate the Emergency response plan 3. Obtain additional supplies from the central supply dept 4. Obtain additional nursing staff to assist in the casualties

2. In an external disaster many victims may be brought to the ED for treatment. The initial nursing action must be to activate the Emergency response plan.

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that two fingers can slide easily between the safety device and the clients skin

2. The safety device straps are secured to the frame and never to the side rail to avoid accidental injury in the event that the side rail is released.

A mother calls the neighbor who is a nurse and tells the nurse that her 3 yr old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? 1. Induce vomiting 2. Call an ambulance 3. Call the Poison Control Center 4. Bring the child to the ED

3. If poisoning occurs, the Poison control center should be contacted immediately.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway.

4. A private room with a private bath is essential if a client has an internal radiation implant.

Contact precautions are initiated for a client with a HCA infection caused by MRSA. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Globes and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and face shield

4. Splashes of body secretions can occur when providing colostomy care.

The nurse enters a clients room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the nursing action? 1. Call for help 2. Extinguish the fire 3. Activate the fire alarm 4. Confine the fire by closing the room door

3. The order of priority in the event of a fire is to use the pnuemonic RACE. Rescute, alarm, confine, extinguish

The nurse is giving a report to an unlicensed assistive personnel who will be caring for a client who has hand restraints. The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 mins

4. The nurse should instruct the UAP to check safety devices and skin integrity every 30 mins. The neurovascular and circulatory status of the extremity should also be checked every 30 mins. The safety device should be removed at least every 2 hours to permit muscle excercise and to promote circulation.