Fundamentals Of Nursing NCLEX Quiz 35

1. What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?

A cotton ball

A penlight

An ophthalmoscope

A tongue depressor and flashlight

Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated.

Explanation

Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated.

2. Which technique would be best in caring for a client following receiving a diagnosis of a state IV tumor in the brain?

Offering the client pamphlets on support groups for brain cancer

Asking the client if there is anything he or his family needs

Reminding the client that advances in technology are occurring everyday

Providing accurate information about the disease and treatment options

Providing information for the client is the best technique for a new diagnosis.

Explanation

Providing information for the client is the best technique for a new diagnosis.

3. 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?.

Implement contact precautions when handling the client..

Educate the client and family members on ways to prevent transmission of VRE..

Monitor the results of the laboratory culture and sensitivity test..

Collaborate with other departments when the client is transported for ordered test..

All hospital personnel who care for the client are responsible for correct implementation of contact precautions.Options B. C. and D: The other options should be carried out by a licensed nurse.

Explanation

All hospital personnel who care for the client are responsible for correct implementation of contact precautions.Options B. C. and D: The other options should be carried out by a licensed nurse.

4. An 8.5 lb. 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?

Administer insulin

Administer oxygen

Feed the infant glucose water (10%)

Place infant in a warmer

After birth. the infant of a diabetic mother is often hypoglycemic.

Explanation

After birth. the infant of a diabetic mother is often hypoglycemic.

5. A 29-year-old client is diagnosed with scarlet fever. Which of the following is the most appropriate type of isolation for this client?.

Airborne..

Contact..

Droplet..

Standard..

Tonsillitis is contagious and is spread by droplet transmission.

Explanation

Tonsillitis is contagious and is spread by droplet transmission.

6. Which of the following infection control activity should be delegated to an experienced nursing assistant?.

Asking clients about the duration of antibiotic therapy..

Demonstrating correct handwashing techniques to client and family..

Disinfecting blood pressure cuffs after clients are discharged..

Screening clients for upper respiratory tract symptoms..

Nursing assistants can follow agency protocol to disinfect items that come in contact wth intact skin by cleaning with chemicals such as alcohol.Options A. B. and D: The other options should be carried out by a licensed nurse.

Explanation

Nursing assistants can follow agency protocol to disinfect items that come in contact wth intact skin by cleaning with chemicals such as alcohol.Options A. B. and D: The other options should be carried out by a licensed nurse.

7. 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?.

The client can be placed in a room with another client with measles (rubeola)..

A special mask (N95) should be worn when working with the client..

Must maintain a spatial distance of 3 feet..

Gloves should be only worn when giving direct care..

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.

Explanation

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.

8. 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 travel blogger who needs tuberculosis testing after an exposure to a person with TB during his trip..

An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg wound infection..

A pregnant woman with a blister-like rash on the face and is possibly having varicella..

An infant with a runny nose and whose older brother has pertussis..

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.

Explanation

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.

9. The nurse assesses a prolonged late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing intervention would be to:

Turn off the infusion

Turn the client to the left

Change the fluid to Ringer’s Lactate

Increase mainline IV rate

Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus. which is a possible cause of the deceleration.

Explanation

Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus. which is a possible cause of the deceleration.

10. What question would be most important to ask a male client who is in for a digital rectal examination?

“Have you noticed a change in the force of the urinary system?”

“Have you noticed a change in tolerance of certain foods in your diet?”

“Do you notice polyuria in the AM?”

“Do you notice any burning with urination or any odor to the urine?”

This change would be most indicative of a potential complication with (BPH) benign prostate hypertrophy.

Explanation

This change would be most indicative of a potential complication with (BPH) benign prostate hypertrophy.