Fundamentals Of Nursing NCLEX Quiz 34

1. You are caring for a newly admitted client with increasing dyspnea and dehydration who has possible avian influenza (bird flu). Which of these prescribed actions will you implement first?.

Administer the first dose of oseltamivir (Tamiflu)..

Obtain blood and sputum specimens for testing..

Provide oxygen using a non-rebreather mask..

Infuse 5% dextrose in water at 75ml/hr..

Because the respiratory manifestations associated with avian influenza are potentially life-threatening. the nurse’s initial action should be to start oxygen therapy.Options A. B. and D: The other interventions should be implemented after addressing the client’s respiratory problem.

Explanation

Because the respiratory manifestations associated with avian influenza are potentially life-threatening. the nurse’s initial action should be to start oxygen therapy.Options A. B. and D: The other interventions should be implemented after addressing the client’s respiratory problem.

2. As the infection control nurse in an acute care hospital. which action will you take to most effectively reduce the incidence of health-care-associated infections?.

Screen all newly admitted clients for colonization or infection with MRSA..

Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms..

Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital..

Require nursing staff to don gowns to change wound dressings for all clients..

Because the hands of health care workers are the most common means of transmission of infection from one client to another. the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use.Option A: Although some hospitals have started screening newly admitted clients for MRSA. there is no evidence that this decreases the spread of infection.Option B: Because administration of antibiotics to individuals who are colonized by bacteria may promote the development of antibiotic resistance. antibiotic use should be restricted to clients who have clinical manifestations of infection.Option D: Wearing a gown to care for clients who are not on contact precautions is not necessary.

Explanation

Because the hands of health care workers are the most common means of transmission of infection from one client to another. the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use.Option A: Although some hospitals have started screening newly admitted clients for MRSA. there is no evidence that this decreases the spread of infection.Option B: Because administration of antibiotics to individuals who are colonized by bacteria may promote the development of antibiotic resistance. antibiotic use should be restricted to clients who have clinical manifestations of infection.Option D: Wearing a gown to care for clients who are not on contact precautions is not necessary.

3. 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? (1. Take off the gown.||2. Remove N95 respirator.||3. Perform hand hygiene.||4. Take off goggles.||5. Remove gloves.)

5. 4. 1. 2. 3.

4. 5. 2. 1. 3.

1. 2. 4. 5. 3.

2. 4. 2. 1. 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.

Explanation

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.

4. A client who states that he may have been contaminated by anthrax arrives at the ED. The following actions are part of the ED protocol for possible anthrax exposure or infection. Which action will you take first?.

Escort the client to a decontamination room..

Assess the client for signs of infection..

Notify hospital security personnel about the client..

Administer ciprofloxacin (Cipro) 250 mg PO..

To prevent contamination of staff or other clients by anthrax. decontamination of the client by removal and disposal of clothing and showering is the initial action in possible anthrax exposure.Option B: Assessment of the client for signs of infection should be before decontamination.Option C: Notification of security personnel is necessary in the case of possible bioterrorism. but this should occur before decontaminating and caring for the client.Option D: According to the CDC guidelines. antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax.

Explanation

To prevent contamination of staff or other clients by anthrax. decontamination of the client by removal and disposal of clothing and showering is the initial action in possible anthrax exposure.Option B: Assessment of the client for signs of infection should be before decontamination.Option C: Notification of security personnel is necessary in the case of possible bioterrorism. but this should occur before decontaminating and caring for the client.Option D: According to the CDC guidelines. antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax.

5. Which of the following information about a client who has meningococcal meningitis has the best indicator that you can discontinue droplet precautions?.

Cough is productive of clear. nonpurulent mucus..

Pupils are equal and reactive to light..

Temperature is lower than 100°F (37.8°C)..

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.

Explanation

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.

6. 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?.

There are several children receiving chemotherapy on the unit..

The infection control nurse liaison is not on the unit today..

The unit is not staffed with the usual number of RNs..

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.

Explanation

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.

7. 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?.

Place the client on contact precaution..

Instruct the client about correct handwashing..

Obtain stool specimens for culture..

Notify the physician about the loose stools..

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.

Explanation

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.

8. You are preparing to care for a 6-year-old who has just undergone allogeneic stem cell transplantation and will need protective environmental isolation. Which nursing tasks will you delegate to a nursing assistant? Select all that apply..

Posting the precautions for protective isolation o the door of the client’s room..

Stocking the client’s room with the needed PPE items..

Talking to the family members about the reasons for the isolation..

Reminding visitors to wear a respirator mask. gloves. and gown..

Teaching the client to perform thorough hand washing after using the bathroom.

Because all staff who care for clients should be familiar with the various type of isolation. the nursing assistant will be able to stock the room and post the precautions on the client’s door. Reminding visitors about previously taught information is a task that can be done by the nursing assistant. although the RN is responsible for the initial teaching.Options C and E: Client teaching and discussion of the reason for protective isolation fall within the RN-level scope of practice.

Explanation

Because all staff who care for clients should be familiar with the various type of isolation. the nursing assistant will be able to stock the room and post the precautions on the client’s door. Reminding visitors about previously taught information is a task that can be done by the nursing assistant. although the RN is responsible for the initial teaching.Options C and E: Client teaching and discussion of the reason for protective isolation fall within the RN-level scope of practice.

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9. You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use. Select all that apply.

Gloves..

N95 respirator..

Surgical Mask..

Googles..

Gown.

A gown and gloves should be used when coming in contact with linens that may be decontaminated by the client’s wound secretions.Options B. C. and D: The other items are not necessary because transmission by splashes. droplets. or airborne means will not occur when the bed is changed.

Explanation

A gown and gloves should be used when coming in contact with linens that may be decontaminated by the client’s wound secretions.Options B. C. and D: The other items are not necessary because transmission by splashes. droplets. or airborne means will not occur when the bed is changed.

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10. 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.

Goggles..

Gown..

Gloves..

Shoe covers..

N95 respirator.

Surgical face mask.

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.

Explanation

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.

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