Exam 4 study guide

Which of the following is correct regarding wound debridement? A. It allows the healthy tissue to regenerate. B. When performed by autolytic means, the wound is irrigated. C. Mechanical methods involve direct surgical removal of the eschar layer of the wound. D. Enzymatic debridement may be implemented independently by the nurse whenever it is required.

A. It allows the healthy tissue to regenerate.

Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure? a. She says to her husband, "Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food." b. "I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital." c. "I understand it will be several weeks before all the radiation leaves my body." d. "I brought several craft projects to do while the radium is inserted."

"I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital." The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed. People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. This statement is not true. As soon as the radiation source is removed (probably 36 to 72 hours after insertion), the client is no longer contaminated with radioactivity. Craft projects usually require the client to sit. The client must remain flat with very little head elevation during the time the rods are in place.

A 4-year-old child is seen in the emergency department with rashes mostly found on his torso. The nurse obtained a medical history from the mother and she said her child had fever before the rashes appeared. Other symptoms include loss of appetite and he began coughing and complains of a sore throat. With these objective data at hand, the nurse suspects that the child is having? 1. Chicken pox. 2. Shingles. 3. Measles. 4. German measles.

1. Chicken pox.

Which of the following actions, if made by the student nurse, are examples of primary prevention? SELECT ALL THAT APPLY: 1. The student nurse prepares a sterile field before cleaning the inner cannula of a tracheostomy. 2. The student nurse administers a PPD test for employment. 3. The student nurse administers a flu vaccine. 4. The student nurse administers Acyclovir to a patient diagnosed with hepatitis C. 5. The student nurse gives a presentation on diet and exercise. 6. The student nurse gives Bactrim to a patient with a UTI.

1. The student nurse prepares a sterile field before cleaning the inner cannula of a tracheostomy. 3. The student nurse administers a flu vaccine 5. The student nurse gives a presentation on diet and exercise.

Which of the following patients would be in contact precautions? Select-all-that-apply: A. A 8 year old patient with lice. B. A 85 year old patient with CRE (Klebisella Pneumoniae). C. A 65 year old patient with Noravirus. D. A 75 year old patient with Disseminated Herpes Zoster. E. A 12 year old patient with impetigo. F. A 9 year old with RSV.

A. A 8 year old patient with lice. B. A 85 year old patient with CRE (Klebisella Pneumoniae). C. A 65 year old patient with Noravirus. D. A 75 year old patient with Disseminated Herpes Zoster. E. A 12 year old patient with impetigo. F. A 9 year old with RSV. All the answers are correct

When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? A. Clean the area with mild soap, dry, and add a protective moisturizer. B. Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the area. C. Soak the area in normal saline solution. D. Wash the area with an astringent and paint it with povidone-iodine (Betadine).

A. Clean the area with mild soap, dry, and add a protective moisturizer.

A patient is diagnosed with Hepatitis A and is incontinent of stool. What type of precautions would be initiated? A. Contact B. Standard C. Droplet D. Contact and Droplet

A. Contact

You're patient is being transported to special procedures for a PICC line placement. The patient is in droplet precautions. What are your nursing actions to ensure proper transport of the patient? A. Notify the receiving department and place a surgical mask on the patient. B. Place an N95 mask on the patient and notify the receiving department. C. Cancel transport and notify the physician for further orders. D. Notify the receiving department and place goggles, gown, and mask on the patient.

A. Notify the receiving department and place a surgical mask on the patient.

The nurse prepares to irrigate the client's wound. The primary reason for performing this procedure is to: A. Remove debris from the wound B. Decrease scar formation C. Improve circulation from the wound D. Decrease irritation from wound drainage

A. Remove debris from the wound

An older adult client has a large decubitus ulcer that is healing slowly at home. The client needs to be instructed regarding a "good nutritional dietary intake" because: A. The potential for a protein deficiency exists B. The client's dietary habits have probably not been adequate for a normal healthy lifestyle C. There may be an insufficient caloric intake, which can result in poor wound healing D. Practice standards require that nutritional aspects be addressed with every client

A. The potential for a protein deficiency exists

The nurse is providing instructions to a client who has a prescription for a nonsteroidal anti-inflammatory drug (NSAID). What information is priority for the nurse to explain to the client about this medication? A) "Take your medication on an empty stomach." B) "Drink at least 8-10 glasses of water a day while taking your medication." C) "Constipation is common with your medication; include roughage in your diet." D) "Take your medication with food."

B) "Drink at least 8-10 glasses of water a day while taking your medication." Nonsteroidal anti-inflammatory drugs (NSAIDS) are nephrotoxic; keeping the client well hydrated will help prevent kidney damage. Taking the medication with food will decrease gastrointestinal (GI) irritation, but preventing kidney damage is more of a priority. Taking the medication on an empty stomach will increase gastrointestinal (GI) irritation. Constipation is not an issue with

A patient with Disseminated Herpes Zoster requires routine tracheostomy suction. Select the appropriate PPE you will wear: A. Surgical mask, goggles, gown B. N95 mask, face shield, gown, gloves C. N95 mask, gown, face shield D. Surgical mask, face shield, gown, gloves

B. N95 mask, face shield, gown, gloves A patient with Disseminated Herpes Zoster is in airborne AND contact precautions. Therefore, you are required to always wear an N95 mask, gowns, and gloves and to follow standard precautions. In this case (because you are providing trach suction), you will be at risk for splash of mucous or blood on the clothing, skin, and mucous membranes. Therefore, you must wear the required N95 mask ,gown, gloves, AND face shield.

You're providing an in-service on transmission-based precautions to a group of nursing students. Which statement made by a student warrants re-education about the topic? A. "I will make sure that any patient who is in droplet precaution wears a surgical mask when being transported." B. "Patients with airborne diseases such as Meningitis require a special room with negative air pressure." C. "I will always wear a gown and gloves when entering a room of a patient in contact precautions." D. "If I provide care to patients with C. Diff, Noravirus, and Rotavirus infections, I will always wash my hands with soap and water, not hand sanitizer."

B. "Patients with airborne diseases such as Meningitis require a special room with negative air pressure." This statement is FALSE because Meningitis is not a condition that requires airborne precautions but droplet precautions. However, patients with airborne diseases do require a special room with negative air pressure. However, patients with Meningitis do not.

The nurse notes that a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

B. Stage 2

You'rer providing care to a patient with C. Diff. After removing the appropriate PPE, you would perform hand hygiene by: A. Using hand sanitizer B. Using soap and water C. Using soap and water only if hands are soiled but can use hand sanitizer D. Using either hand sanitizer or soap and water

B. Using soap and water After providing care to patients with C. Diff, Noravirus, or Rotavirus, you must perform hand hygiene by washing the hands with ONLY soap and water. Hand-sanitizer is not sufficent enough in killing the germs in these conditions.

1) The nurse is caring for a client who has experienced a sports-related injury to his knee. During the morning assessment, what signs of inflammation will the nurse most likely assess? Select all that apply. A) Pitting edema B) Pallor C) Swelling D) Warmth E) Pain

C) Swelling D) Warmth E) Pain

Which of the following clients is most susceptible to infection? A. A 29-year-old postpartum client B. A 42-year-old client with a recent uncomplicated appendectomy C. A 76-year-old client with a hip fracture D. An 18-year-old athlete with repair of torn knee ligaments

C. A 76-year-old client with a hip fracture

A 6 year old female is diagnosed with Varicella. What type of isolation precautions will be initiated for this patient? A. Droplet B. Airborne C. Airborne and Contact D. Droplet and Contact

C. Airborne and Contact

A client has a viral infection. Which of the following is typical of the illness stage of the course of the infection? A. There are no longer any acute symptoms. B. The client was first exposed to the infection 2 days ago but has no symptoms. C. An oral temperature reveals a very febrile condition. D. The client "feels sick" but is able to continue her normal activities.

C. An oral temperature reveals a very febrile condition.

Select ALL the conditions that warrant airborne precautions: A. Noravirus B. Hepatitis A C. Measles D. Varicella E. Disseminated Varicella Zoster F. Tuberculosis G. Whooping Cough H. RSV I. Epiglottitis

C. Measles D. Varicella E. Disseminated Varicella Zoster F. Tuberculosis The answers are C, D, E, F. Measles, Varicella (chicken pox), Disseminated Varicella Zoster (shingles), and TB require airborne precautions. NOTE: Varicella and Disseminated Varicella Zoster also require contact precaution as well. Noravirus and RSV are contact precautions. Hepatitis A is contact precautions IF the patient is diapered or incontinent of stool. Whooping cough (Pertussis) and Epiglottitis are droplet precautions.

The 25-year-old female is visiting family from Iran and develops signs and symptoms of appendicitis during the night. The client is brought to the Emergency Department by the family. Which nursing intervention is the most culturally sensitive for this client? A) Ask the physicians which one should see the client. B) Ask for a female doctor to assess the client. C) Ask for a male doctor to assess the client. D) Explain the assessment procedure and ask the family their preference.

D) Explain the assessment procedure and ask the family their preference. Culturally competent care means collaborating with the client to determine the client's preferences for medical care. The nurse should not assume that a foreign client will want a male or female doctor. Asking the doctors to decide does not include the client's wishes.

A 78-year-old client admitted to the medical unit is at risk for infection because of the following physiological changes: A. Increased cough reflex B. Thicker, more elastic skin C. Increase in stomach acid D. Reduced salivary production

D. Reduced salivary production

A 29-year-old client is diagnosed with scarlet fever. Which of the following is the most appropriate type of isolation for this client? a. Airborne. b. Contact. c. Droplet. d. Standard.

c. Droplet.

The nurse should expect to administer the first dose of the measles, mumps, and rubella (MMR) vaccine at which age? a. 12 months b. 6 months c. 24 months d. 2 years

a. 12 months The first dose of the measles, mumps, and rubella vaccine should be administered at 12 to 15 months of age. A second dose is administered at 4 to 6 years of age.

The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? a. Clustered skin vesicles b. A generalized body rash c. Small blue-white spots with a red base d. A fiery-red edematous rash on the cheeks

a. Clustered skin vesicles

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? Select all that apply a. Goggles. b. Gown. c. Gloves. d. Shoe covers. e. N95 respirator. f. Surgical face mask.

a. Goggles. b. Gown. e. N95 respirator. Because herpes zoster is spread through airborne means and by direct contact with the lesions, you should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Options A and D: Goggles and shoe covers are not needed for airborne or contact precautions. Option F: Surgical face mask filters only large particles and will not provide protection from herpes zoster.

A young adult is being treated for second and third degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement? a. "I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water." b. "If any healed areas break open I should first cover them with a sterile dressing and then report it." c. "I must wear my Jobst elastic garment all day and can only remove it when I'm going to bed." d. "I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours."

b. "If any healed areas break open I should first cover them with a sterile dressing and then report it." Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow. This cleanses the wounds, especially those that are still open, and removes dead tissue. The client is taught to report changes in wound healing such as blister formation, signs of infection, and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing. The client must be aware that infection of the wound may occur; signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul smelling drainage must be reported immediately.

The home care nurse visits a child recently discharged from the hospital with a diagnosis of hepatitis A virus (HAV) infection. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother? a. "In about 2 months." b. "When the jaundice disappears." c. "One week after the onset of jaundice." d. "At the beginning of the next academic year."

c. "One week after the onset of jaundice." Because HAV is not infectious 1 week after the onset of jaundice, return to school at that time is permitted if the child feels well enough. Options 1, 2, and 4 are incorrect.

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding prevention of the transmission to siblings and other household members. Which instruction should the nurse provide? a. Isolate the child from others for 2 weeks because the virus is transmitted by breathing and coughing. b. Wash sheets and towels used by the child separately in bleach to prevent spread of the infection to others. c. Have the child use a separate bathroom for urination and bowel movements to prevent the spread of infection. d. Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva.

d. Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva. Roseola is transmitted via saliva, so others should not share drinking glasses or eating utensils. The remaining options are not accurate instructions regarding the prevention of the transmission of roseola.

A hospitalized client who has been placed on contact precautions has been prescribed to have a chest radiograph in the radiology department. The nurse should plan to take which action on receipt of this prescription? a. Transport the client through empty corridors only. b. Place a mask on the client in preparation for transport. c. Place a sterile gown on the client in preparation for transport. d. Question the health care provider about whether a portable chest radiograph may be obtained.

d. Question the health care provider about whether a portable chest radiograph may be obtained. The client who is placed on contact precautions has a high microorganism count in some type of body secretion (such as feces or wound drainage). This client is placed in a private room whenever possible and is removed from the room only when absolutely necessary. Client transport should be done only for essential purposes. Notification of departmental personnel and disinfection of any environmental surfaces with which the client has contact are imperative.

The community health nurse is providing information to parents of children in a local school regarding the signs of meningitis. The nurse informs the parents that the classic signs/symptoms of meningitis include which findings? a. Nausea, delirium, and fever b. Severe headache and back pain c. Photophobia, fever, and confusion d. Severe headache, fever, and a change in the level of consciousness

d. Severe headache, fever, and a change in the level of consciousness

When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following? a. A reduced white blood cell count b. A decreased platelet count c. Shallow respirations d. Tachypnea

d. Tachypnea The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations, altered white blood cell or platelet counts are not specific signs of metabolic imbalance.

Which of the following could contribute to causing a nosocomial infection? A. Washing hands before applying a dressing B. Taping a plastic bag to the bed rail for tissue disposal C. Placing a Foley catheter bag on the bed when transferring a client D. Using Betadine to cleanse the skin before starting an intravenous line

C. Placing a Foley catheter bag on the bed when transferring a client

You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? Take off the gown. Remove N95 respirator. Perform hand hygiene. Take off goggles. Remove gloves. a. 5, 4, 1, 2, 3 b. 4, 5, 2, 1, 3 c. 1, 2, 4, 5, 3 d. 2, 4, 2, 1, 3

a. 5, 4, 1, 2, 3 The sequence will prevent contact of the contaminated gloves and gowns with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. a. Activities should be resumed gradually. b. Avoid contact with other individuals, except family members, for at least 6 months. c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. d. Respiratory isolation is not necessary because family members already have been exposed. e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. f. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

a. Activities should be resumed gradually. c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. d. Respiratory isolation is not necessary because family members already have been exposed. e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

Jayson, 1 year old child has a staph skin infection. Her brother has also developed the same infection. Which behavior by the children is most likely to have caused the transmission of the organism? a. Bathing together. b. Coughing on each other. c. Sharing pacifiers. d. Eating off the same plate.

a. Bathing together. Direct contact is the mode of transmission for staphylococcus. Staph is not spread by coughing. Staph is not spread through oral secretions. Direct contact is required. Staph is not spread through oral secretions.

The nurse employed on a medical unit in a hospital receives a telephone call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions? a. Droplet precautions b. Enteric precautions c. Contact precautions d. Protective isolation

a. Droplet precautions

You are a school nurse. Which action will you take to have the most impact on the incidence of infectious disease in the school? a. Ensure that students are immunized according to national guidelines. b. Provide written information about infection control to all patients. c. Make soap and water readily available in the classrooms. d. Teach students how to cover their mouths when coughing.

a. Ensure that students are immunized according to national guidelines. The incidence of once common infectious diseases such as measles, chickenpox, and mumps has been most effectively reduced by immunization of all school-aged children. Options B, C, and D: The other options are also helpful but will not have as great as impact as immunization.

The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions should the nurse include in performing this procedure? Select all that apply. a. Explaining the procedure to the client b. Clamping the tubing of the drainage bag c. Aspirating a sample from the port on the drainage tubing d. Obtaining the specimen from the urinary drainage bag e. Wiping the port with an alcohol swab before inserting the syringe

a. Explaining the procedure to the client b. Clamping the tubing of the drainage bag c. Aspirating a sample from the port on the drainage tubinge. e. Wiping the port with an alcohol swab before inserting the syringe

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client's care? a. Implement contact precautions when handling the client. b. Educate the client and family members on ways to prevent transmission of VRE. c. Monitor the results of the laboratory culture and sensitivity test. d. Collaborate with other departments when the client is transported for ordered test.

a. Implement contact precautions when handling the client.

A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells you that he is having frequent watery stools. Which action will you take first? a. Place the client on contact precaution. b. Instruct the client about correct handwashing. c. Obtain stool specimens for culture. d. Notify the physician about the loose stools

a. Place the client on contact precaution. The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be able to place him on contact precautions to prevent the spread of C. difficile to other clients. Options B, C, and D: The other actions are also needed and should be taken after placing the client on contact precautions.

A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority? a. Ineffective airway clearance related to edema b. Disturbed body image related to physical appearance c. Impaired urinary elimination related to fluid loss d. Risk for infection related to epidermal disruption

a. Ineffective airway clearance related to edema Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on assessing and managing an effective airway. Body image disturbance, impaired urinary elimination, and infection are all integral parts of burn management but aren't the first priority.

A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? a. Instituting droplet precautions b. Administering acetaminophen (Tylenol) c. Obtaining history information from the parents d. Orienting the parents to the pediatric unit

a. Instituting droplet precautions

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound

a. Low serum albumin level With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

a. Maintaining the patient's blood glucose within a normal range Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition also is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing

A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having a severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? a. Place the client on contact and airborne precautions. b. Obtain blood, urine, and sputum for cultures. c. Administer methylprednisolone (Solu-Medrol) 1 gram/IV. d. Infuse normal saline at 100ml/hr.

a. Place the client on contact and airborne precautions. Since SARS is a severe disease with a high mortality rate, the initial action should be to protect other clients and health care workers by placing the client in isolation. If an airborne-agent isolation (negative pressure) room is not available in the ED, droplet precautions should be initiated until the client can be moved to a negative-pressure room. Options B, C, and D: The other options should also be taken rapidly but are not as important as preventing transmission of the disease.

The nurse is reviewing the white blood cell (WBC) count and differential on a client and notes that the results indicate a left shift. What are the possible indications for these laboratory results? Select all that apply. a. The total number of WBCs b. An increased number of bands c. The presence of an acute infectious process d. An increased number of mature neutrophils e. An increased number of immature neutrophils

a. The total number of WBCs b. An increased number of bands c. The presence of an acute infectious processe. e. An increased number of immature neutrophils

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? a. Surgical mask and gloves b. Particulate respirator, gown, and gloves c. Particulate respirator and protective eyewear d. Surgical mask, gown, and protective eyewear

b. Particulate respirator, gown, and gloves The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.

Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions? a. A diagnosis of AIDS and cytomegalovirus b. A positive PPD with an abnormal chest x-ray c. A tentative diagnosis of viral pneumonia d. Advanced carcinoma of the lung

b. A positive PPD with an abnormal chest x-ray The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.

An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a pre-employment physical. Although frightened about her diagnosis, she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible? a. Hands. b. Droplet nuclei. c. Milk products. d. Eating utensils.

b. Droplet nuclei Hands are the primary method of transmission of the common cold. The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected person. The tubercle bacillus is not transmitted by means of contaminated food. Contact with contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid, or cholera. The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating utensils

A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation? a. Masks should be worn with all client contact. b. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. c. Isolation gowns are not needed. d. A private room is always indicated.

b. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client's hygiene is poor.

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client? a. Reverse isolation b. Respiratory isolation c. Standard precautions d. Contact isolation

b. Respiratory isolation Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient's sputum is expected. A private room and BSI, along with good hand washing techniques, are the best defense against the spread of MRSA pneumonia.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a. Red, hard skin b. Serous drainage c. Purulent drainage d. Warm, tender skin

b. Serous drainage Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

You are the pediatric unit charge nurse today and is working with a new RN. Which action by the new RN requires the most immediate action on your part? a. The new RN tells the nursing assistant to use an N95 respirator mask when caring for a child who has pertussis. b. The new RN places a child who has chemotherapy-induced neutropenia into a negative-pressure room. c. The new RN admits a new client with respiratory syncytial virus (RSV) infection to a room with another child who has RSV. d. The new RN wears goggles to change linens of a client who has diarrhea caused by C. difficile.

b. The new RN places a child who has chemotherapy-induced neutropenia into a negative-pressure room. Clients who are neutropenic should be placed in positive-airflow rooms; placement of the child in a negative airflow room will increase the likelihood of infection for this client. Options A and D: The use of an N95 respirator is not necessary for pertussis, and goggles are not needed for changing the linens of clients infected with C. difficile; however, these protections do not increase the risk to the clients. Option C: Although private rooms are preferred for clients who need droplet precautions, such as client with RSV infection, they can be placed in rooms with other clients who are infected with the same microorganism.

The nurse is reviewing the laboratory results for a client with a diagnosis of leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets this to mean that the client is at risk for which problem? a. Anemia b. Bleeding c. Infection d. Dehydration

c. Infection

A newly admitted client with streptococcal pharyngitis (tonsillitis) has been placed on droplet precaution. Which of the following statements indicates the best understanding for this type of isolation? a. The client can be placed in a room with another client with measles (rubeola). b. A special mask (N95) should be worn when working with the client. c. Must maintain a spatial distance of 3 feet. d. Gloves should be only worn when giving direct care.

c. Must maintain a spatial distance of 3 feet The most common forms of transmission of an organism in a client with tonsillitis are through coughing, sneezing, and talking. Droplets can travel no more than 3ft so precautions should be maintained when there is a possibility of entering this distance. Option A: Client requires a private room. Option B: An N95 mask is not required for this client. A face mask instead can be used when dealing with the client. Option D: Gloves, gowns, face mask and eye protection should be worn in giving direct care.

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST? a. Institute seizure precautions b. Assess neurologic status c. Place in respiratory isolation d. Assess vital signs

c. Place in respiratory isolation The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection.

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. a. The nurse who never had roseola b. The nurse who never had mumps c. The nurse who never had chickenpox d. The nurse who never had German measles e. The nurse who never received the varicella-zoster vaccine

c. The nurse who never had chickenpoxe. e. The nurse who never received the varicella-zoster vaccine

A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home and asks the nurse if the child is infectious to the other children. Which response by the nurse is most appropriate? a. "The infectious period occurs after the lesions begin." b. "The infectious period begins with the onset of the rash." c. "The infectious period is not known, and it is possible that the children may develop the chickenpox within the next 2 weeks." d. "The infectious period begins 1 to 2 days before the onset of the rash and ends about 5 days after the onset of the lesions and crusting of the lesions."

d. "The infectious period begins 1 to 2 days before the onset of the rash and ends about 5 days after the onset of the lesions and crusting of the lesions." The infectious period of chickenpox is 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and the crusting of the lesions. The remaining options are inaccurate statements.

The nurse instructs an older client with arthritis on the side effects of nonsteroidal anti-inflammatory drug (NSAID) therapy. Which client statement would indicate that teaching had been effective? A) "I will Report any abnormal bruising." B) "Caffeine will decrease the effectiveness of the medication." C) "I cannot take other medications." D) "If I have a change in my mood I will call the prescriber."

A) "I will Report any abnormal bruising." Elderly clients are at risk for increased bleeding with nonsteroidal anti-inflammatory drug (NSAID) therapy. The client should be taught to report any abnormal bruising, which may indicate bleeding. Elderly clients often take several medications, and refraining from taking them with NSAIDs is an unrealistic outcome. Mood changes are not a side effect of NSAID therapy. There is no reason for avoiding use of caffeine while using an NSAID.

A client was admitted with complaints of an elevated temperature,, nausea, and pain and tenderness in the lower right quadrant of the abdomen. After receiving pain medication, the client continues to complain of pain at a level of 8 of 10 on the pain scale. Pain medications are not due for at least another 2 hours. What should the nurse say? A) "I will inform the physician about your continued pain." B) "I do not have any medications ordered for you at this time." C) "Why don't you try to rest for a while longer until it is time?" D) "Let's try a heating pad or warm blanket."

A) "I will inform the physician about your continued pain." The client's inability to achieve comfort will need to be reported to the physician. The reported manifestations are consistent with appendicitis and the client is at risk for perforation, which is manifested by increased pain. The use of heat to manage the pain is contraindicated due to the risk of perforation. Advising the client that no medications are available at this time and encouraging rest do not meet the concerns being presented by the client.

The client has a 6-inch laceration on his right forearm that develops an infection. Which of the following is a sign of an acute inflammatory process? A. A decrease in the number of white blood cells B. A release of histamine that adds to the pain response C. A blanching of the skin D. A decrease in temperature at the site

B. A release of histamine that adds to the pain response

A child receives a vaccine for measles, mumps, and rubella. The client has experienced which type of immunity? A. Natural immunity B. Artificial immunity C. Passive immunity D. Complete immunity

B. Artificial immunity

The client has an alteration in skin integrity on the left heel area. The nurse decides to use the Braden Scale instead of the Gosnell Scale of Assessment. Which category of assessment will the nurse now be able to use? The degree of: A. Mobility B. Friction and shear C. The effects of nutrition D. Physical activity

B. Friction and shear

A client is admitted with airway edema, bronchoconstriction, and increased mucus production after being exposed to an allergen. What care will the client need to address this inflammation to the respiratory system? Select all that apply. A) Turn and reposition every 2 hours. B) Monitor oxygen saturation. C) Administer oxygen as prescribed. D) Restrict fluids. E) Monitor lung sounds.

B) Monitor oxygen saturation. C) Administer oxygen as prescribed.E) Monitor lung sounds.

Select ALL the patients that would be placed in droplet precautions: A. A 5 year old patient with Chicken Pox. B. A 36 year old patient with Pertussis. C. A 25 year old patient with Scarlet Fever. D. A 56 year old patient with Tuberculosis. E. A 69 year old patient with Streptococcal Pharyngitis. F. A 89 year old patient with C. Diff.

B. A 36 year old patient with Pertussis. C. A 25 year old patient with Scarlet Fever. E. A 69 year old patient with Streptococcal Pharyngitis The answers are B, C, E. Patients with Pertussis (Whooping Cough), Scarlet Fever, and Streptococcal Pharyngitis are to be placed in droplet precautions. Patients with TB are to placed in airborne precautions while a patient with Chicken Pox should be place in both airborne and contact precautions. Patients with C. Diff are to be placed in contact precautions.

The nurse is caring for a client from India who has extensive deep tissue damage. The nurse notes that the client is also vegan. Which dietary information should the nurse teach this client to enhance the healing process? A) "A low-fat, high-carbohydrate, low-protein diet is best for healing." B) "A high-fat, low-carbohydrate diet is best for healing." C) "A high-carbohydrate, high-protein diet is best for healing." D) "A diet high in protein and vitamin D is best for healing."

C) "A high-carbohydrate, high-protein diet is best for healing." Carbohydrates are important to meet the energy demands of healing, and protein is needed is needed for cell growth. The vegan client needs to be taught to eat proteins that provide the essential amino acids that can be lacking in a vegan diet. Fats are needed in moderation for the development of cell membranes. Vitamins necessary to promote healing are C, K, A, and the B-complex vitamins.

The nurse in a rheumatology clinic is managing care for clients who receive nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of their disease process. What are the primary laboratory tests the nurse will assess prior to initiation of therapy? Select all that apply. A) Serum amylase B) Electrolytes C) Creatine clearance D) Complete blood count (CBC) E) Liver function tests

C) Creatine clearance D) Complete blood count (CBC) E) Liver function tests It is important to assess the client's creatine clearance to determine kidney function prior to initiation of nonsteroidal anti-inflammatory drug (NSAID) therapy. It is also important to assess the client's liver function tests and complete blood count (CBC) prior to initiation of NSAID therapy. There is no need to assess the client's electrolytes or serum amylase; these are not factors that are affected by NSAIDs.

The nurse is caring for a client with severe inflammation. Which assessment findings would indicate a systemic reaction to inflammation? Select all that apply. A) Erythema B) Edema C) Pain D) Tachypnea E) Tachycardia

D) Tachypnea E) Tachycardia If the nurse observes a systemic reaction, the client will exhibit manifestations including temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment indicate a local reaction.

The nursing instructor determines that the nursing student understands the purposes of standard and transmission-based precautions if which statements are made? Select all that apply. a. "They prevent transmission of organisms from client to client." b. "They prevent transmission of organisms from health care providers to clients." c. "They prevent transmission of organisms from clients to health care providers." d. "They prevent transmission of organisms from hospital visitors to in-hospital clients." e. "They prevent transmission of organisms from hospital visitors to health care providers." f. "They prevent transmission of organisms from health care providers and clients to people outside of the hospital."

a. "They prevent transmission of organisms from client to client." b. "They prevent transmission of organisms from health care providers to clients." c. "They prevent transmission of organisms from clients to health care providers." f. "They prevent transmission of organisms from health care providers and clients to people outside of the hospital."

While working in a pediatric clinic, you receive a telephone call from the parent of a 10-year-old who is receiving chemotherapy for leukemia. The client's sibling has chickenpox. Which of these actions will you anticipate taking next? a. Teach the parents regarding contact and airborne precaution. b. Administer varicella-zoster immune globulin to the client. c. Prepare the client for admission to a private room in the hospital. d. Educate the parent about the correct use of acyclovir (Zovirax).

b. Administer varicella-zoster immune globulin to the client. Varicella-zoster immune globulin administration can prevent the development of chickenpox in high-risk clients and will typically be prescribed. Option A: Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child develops varicella. Options C and D: Hospitalization and acyclovir therapy may be required if the child develops a varicella-zoster virus infection

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for which condition? a. Anemia b. Infection c. Bleeding d. Dehydration

b. Infection Granulocytes are blood cells that destroy bacteria. When granulocytes are decreased from normal, the risk of infection increases significantly. A decreased granulocyte count is not associated with anemia, bleeding, or dehydration.

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? a. Leukopenia with a shift to the left b. Leukocytosis with a shift to the left c. Leukopenia with a shift to the right d. Leukocytosis with a shift to the right

b. Leukocytosis with a shift to the left Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appenditis.

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? a. Initiate strict enteric precautions. b. Move the infant to a room with another child with RSV. c. Leave the infant in the present room because RSV is not contagious. d. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.

b. Move the infant to a room with another child with RSV. RSV is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care is necessary. Using good hand-washing technique and wearing gloves and gowns are also necessary. Masks are not required. An infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are unnecessary

A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of the child, the nurse should plan to place the child on which precautions? a. contact b. airborne c. neutropenic d. droplet

b. airborne Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne droplet precautions are required, and persons in contact with the child should wear masks. The child is placed in a private room if hospitalized, and the hospital room door remains closed. Gowns and gloves are unnecessary, but standard precautions are used. Articles that are contaminated should be bagged and labeled. Special enteric precautions and protective (neutropenic) isolation are not indicated in rubeola.

Gracie, the mother of a 3-month-old infant calls the clinic and states that her child has a diaper rash. What should the nurse advice? a. "Switch to cloth diapers until the rash is gone" b. "Use baby wipes with each diaper change." c. "Leave the diaper off while the infant sleeps." d. "Offer extra fluids to the infant until the rash improves."

c. "Leave the diaper off while the infant sleeps." Leaving the diaper off while the infant sleeps helps to promote air circulation to the area, improving the condition. Switching to cloth diapers isn't necessary; in fact, that may make the rash worse. Baby wipes contain alcohol, which may worsen the condition. Extra fluids won't make the rash better.

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the schoolchildren. Which statement made by a parent indicates a need for further teaching regarding this communicable disease? a. "Small blue-white spots with a red base may appear in the mouth." b. "The rash usually begins on the face and spreads downward toward the feet." c. "The disease can be spread to others from 10 days before any sign of the disease appears to 15 days after the rash appears." c. "Respiratory symptoms such as a profuse runny nose, cough, and fever occur before the development of a rash."

c. "The disease can be spread to others from 10 days before any sign of the disease appears to 15 days after the rash appears." The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal stage. All other options are accurate descriptions of rubeola, so they would not indicate a need for further teaching. The small blue-white spots found in this communicable disease are called Koplik's spots. The incorrect option describes the incubation period for rubella, not rubeola

The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff? a. The nurse aide is not wearing gloves when feeding an elderly client. b. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing. c. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. d. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.

c. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves. Strict isolation requires the use of mask, gown, and gloves.

Malcolm is a newly assigned as a triage nurse, on his first day of work, the following clients arrive at the ED. Which among the client require the most rapid action to protect other clients in the ED from infection? a. A travel blogger who needs tuberculosis testing after an exposure to a person with TB during his trip. b. An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg wound infection. c. A pregnant woman with a blister-like rash on the face and is possibly having varicella. d. An infant with a runny nose and whose older brother has pertussis.

c. A pregnant woman with a blister-like rash on the face and is possibly having varicella. Chickenpox (Varicella) is transmitted by airborne and that can be easily transferred to the other clients in the emergency unit. The pregnant woman with the rash should be isolated right away from other clients through placement in a negative-pressure room. Option A: The client who has been exposed to TB does not place the other clients at risk for infection because there are no symptoms of active TB. Options B and D: Droplet and contact precautions should be instituted for the clients with pertussis and MRSA infection, but this can be done after isolating the client with possible varicella.

The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions? a. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood. b. An aide wears gloves to feed a helpless client. c. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy. d. A pregnant worker refuses to care for a client known to have AIDS.

c. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy. Masks and protective eye wear are indicated anytime there is great potential for splashing of body fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a tracheostomy are likely to have blood in the sputum.

A child is sent to the school nurse by the teacher. On assessment of the child the nurse notes the presence of a rash. The nurse suspects that the child has erythema infectiosum (fifth disease) based on which assessment finding? a. A discrete rose-pink maculopapular rash on the trunk b. A highly pruritic, profuse macule-to-papule rash on the trunk c. Erythema on the face, giving a "slapped cheeks" appearance d. A discrete pinkish-red maculopapular rash on the arms and trunk

c. Erythema on the face, giving a "slapped cheeks" appearance

Which action will you take to most effectively reduce the incidence of hospital-associated urinary tract infections? a. Teach assistive personnel how to provide good perineal hygiene. b. Ensure that clients have enough adequate fluid intake. c. Limit the use of indwelling foley catheter (IFC). d. Perform dipstick urinalysis for clients with risk factors for UTI.

c. Limit the use of indwelling foley catheter (IFC). The most effective way to reduce the incidence of UTIs in the hospital setting is to avoid using retention catheters. Options A, B, and D: These actions also reduce the risk for and/or detect UTI, but avoidance of indwelling catheter will be more effective.

The nursing student is reviewing information related to the primary purpose of neutrophils in the inflammatory response. The nursing instructor determines that understanding is accurate when which statement is made by the student? a. "Neutrophils dilate the blood vessels." b. "Neutrophils increase fluids at the site of injury." c. "Neutrophils allow permeability of the blood vessels." d. "Neutrophils phagocytize any potentially harmful agents."

d. "Neutrophils phagocytize any potentially harmful agents."

The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? a. "We need to encourage our child to drink fluids." b. "Coughing spells may be triggered by dust or smoke." c. "Vomiting may occur when our child has coughing episodes." d. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."

d. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks." Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are accurate components of home care instructions.

You are caring for four clients who are receiving IV infusions of normal saline. Which client is at 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 nontunneled central line in the left internal jugular vein.

d. A client who has nontunneled central line in the left internal jugular vein. Several factors increase the risk for infection for this client: central lines are associated with a higher infection risk, the skin of the neck and chest having a high number of microorganisms, and the line is tunneled. Options A and B: Peripherally inserted IV lines such as midline catheters and PICC line are associated with a lower incidence of infection. Option C: Implanted ports are placed under the skin and so are less likely to be associated with catheter infection than a nontunneled central IV line.

Which of the following information about a client who has meningococcal meningitis has the best indicator that you can discontinue droplet precautions? a. Cough is productive of clear, nonpurulent mucus. b. Pupils are equal and reactive to light. c. Temperature is lower than 100°F (37.8°C). d. Appropriate antibiotics have been given for 24 hours.

d. Appropriate antibiotics have been given for 24 hours. Current CDC evidenced-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy for 24 hours. Options A, B, and C: The other information may indicate that the client's condition is improving but does not indicate that droplet precaution should be discontinued.

The nurse is caring for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). A highly sensitive C-reactive protein (hsCRP) blood test is prescribed. What other blood test is often used along with the hsCRP? a. Cardiac enzymes b. Serum electrolytes c. Complete blood count (CBC) d. Erythrocyte sedimentation rate (ESR)

d. Erythrocyte sedimentation rate (ESR) The hsCRP is a test to measure inflammation in clients with an autoimmune disease such as SLE and is often done with or instead of the ESR. Both tests are very useful for detecting inflammation anywhere in the body. Cardiac enzymes, serum electrolytes, and a CBC are incorrect.

A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective should the nurse wear? a. Gloves b. Gown and gloves c. Gown, gloves, and mask d. Gown, gloves, mask, and eye goggles or eye shield

d. Gown, gloves, mask, and eye goggles or eye shield The transmission of SARS isn't fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any health care worker providing care for a client with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.

You are the charge nurse on the pediatric unit when a pediatrician calls wanting to admit a child with rubeola (measles). Which of these factors is of most concern in determining whether to admit the child to your unit? a. There are several children receiving chemotherapy on the unit. b. The infection control nurse liaison is not on the unit today. c. The unit is not staffed with the usual number of RNs. d. No negative-airflow rooms are available on the unit.

d. No negative-airflow rooms are available on the unit Because clients with rubeola require implementation of airborne precautions, which include placement in a negative airflow room, this child cannot be admitted to the pediatric unit. Options A, B, and C: The other circumstances may require actions such as staff reassignments but would not prevent the admission of a client with rubeola.