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Question Number 1 of 20
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?
| | A) | Reverse |
| | B) | Airbourne |
| | C) | Standard precautions |
| | D) | Contact |
The correct answer is D: Contact
Contact precautions 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 continue 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 contact precautions , along with good hand washing techniques, are the best defenses against the spread of MRSA pneumonia.
Question Number 2 of 20
The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?
| | A) | "The treatment requires reapplication in 8 to 10 days." |
| | B) | "Bedding and clothing can be boiled or steamed." |
| | C) | Children are not to share hats, scarves and combs. |
| | D) | Nit combs are necessary to comb out nits. |
The correct answer is C: “Children are not to share hats, scarves and combs.”
Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair. All of the options are correct statements. However they do not best answer the question of how to prevent the spread of lice in a school setting.
Question Number 3 of 20
Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition?
| | A) | Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) |
| | B) | A positive purified protein derivative with an abnormal chest x-ray |
| | C) | A tentative diagnosis of viral pneumonia with productive brown sputum |
| | D) | Advanced carcinoma of the lung with hemoptasis |
The correct answer is B: A positive purified protein derivative 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. A sputum smear for acid fast bacillus would be done next. CMV usually causes no signs or symptoms in children and adults with healthy immune systems. When signs and symptoms do occur, they''re often similar to those of mononucleosis, including: sore throat, fever, muscle aches, fatigue. Good handwashing is recommended for CMV.
Question Number 4 of 20
The nurse is to administer a new medication to a client. Which actions are in the best interest of the client?
| | A) | Verify the order for the medication. Prior to giving the medication the nurse should say "Please state your name?" |
| | B) | Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" then check the client's name band and allergy band |
| | C) | As the room is entered say "What is your name?" then check the client's name band |
| | D) | Verify the client's allergies on the admission sheet and order. Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?" |
The correct answer is B: Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" then check the client''s name band and allergy band
A dual check is consistently done for a client''s name. This would involve verbal and visual checks. Since this is a new medication an allergy check is appropriate.
Question Number 5 of 20
A mother calls the hospital hot line and is connected to the triage nurse. The mother proclaims: “I found my child with odd stuff coming from the mouth and an unmarked bottle nearby.” Which of these comments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosive substance?
| | A) | Ask the child if the mouth is burning or throat pain is present |
| | B) | Take the child’s pulse at the wrist and see if the child is has trouble breathing lying flat. |
| | C) | What color is the child’s lips and nails and has the child voided today? |
| | D) | Has the child had vomiting or diarrhea or stomach cramps yet? |
The correct answer is A: “Ask the child if the mouth is burning or throat pain is present”
Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful for the overall child’s condition. However, the question is about the concern for a caustic substance
Question Number 6 of 20
A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to
| | A) | Move any chairs or desks at least 3 feet away from the child |
| | B) | Note the sequence of movements with the time lapse of the event |
| | C) | Provide privacy as much as possible to minimize fightening the other children |
| | D) | Place the hands or a folded blanket under the head of the child |
The correct answer is D: Place the hands or a folded blanket under the head of the child
The priority during seizure activity is to protect the person from physical injury. Place a pillow, folded blanket or your hands under the child''s head to prevent harm to the head. The other body parts are of less risk of injury. The sequence of actions above would be options d, a, b, and c in order of priority.
Question Number 7 of 20
A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to handwashing, to be implemented is which of these?
| | A) | Apply appropriate signs outside and inside the room |
| | B) | Apply a mask with a shield if there is a risk of fluid splash |
| | C) | Wear a gown to change soiled linens from incontinence |
| | D) | Have gloves on while handling bedpans with feces |
The correct answer is D: Have gloves on while handling bedpans with feces
The specific measure to prevent the spread of hepatitis A is careful handling and protection while handling fecal material. All of the other actions are correct but not the most significant
Question Number 8 of 20
Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?
| | A) | Sensory perceptual alterations related to decreased vision |
| | B) | Alteration in mobility related to fatigue |
| | C) | Impaired gas exchange related to retained secretions |
| | D) | Altered patterns of urinary elimination related to nocturia |
The correct answer is D: Altered patterns of urinary elimination related to nocturia
Nocturia is especially problematic because many elders fall when they rush to reach the bathroom at night. They may be confused or not fully alert. Inadequate lighting can increase their chances of stumbling and they may fall over furniture or carpets.
Question Number 9 of 20
The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement?
| | A) | Have the client cough into a tissue and dispose in a separate bag |
| | B) | Instruct the client to cover the mouth with a tissue when coughing |
| | C) | Reinforce for all to wash their hands before and after entering the room |
| | D) | Place client in a negative pressure private room and have all who enter the room use masks with shields |
The correct answer is D: Place client in a negative pressure private room and have all who enter the room use masks with shields
A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. Tuberculosis (TB) is caused by spore-forming mycobacteria, more often Mycobacterium tuberculosis. In developed countries the infection is airborne and is spread by inhalation of infected droplets. In underdeveloped countries (Africa, Asia, South America), transmission also occurs by ingestion or by skin invasion, particularly when bovine TB is poorly controlled.
Question Number 10 of 20
The mother of a toddler who is being treated for pesticide poisoning asks: “Why is activated charcoal used? What does it do?” What is the nurse's best response?
| | A) | "Activated charcoal decreases the systemic absorption of the poison from the stomach." |
| | B) | "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." |
| | C) | "This substance helps to get the poison out of the body by the gastrointestinal system." |
| | D) | "The action may bind or inactivate the toxins or irritants that are ingested by children or adults." |
The correct answer is B: "The charcoal absorbs the poison and forms a compound that doesn''t hurt your child."
All of the options are correct responses. However, option b is most accurate information to answer the mother’s question and about the effectiveness of activated charcoal. The language is appropriate for a parent''s understanding.
Question Number 11 of 20
A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:
| | A) | Visitors must wear a mask and a gown |
| | B) | There are no special requirements for visitors of clients on contact precautions |
| | C) | Visitors should wash their hands before and after touching the client |
| | D) | Visitors should wear gloves if they touch the client |
Your response was "A".
The correct answer is C: Visitors should wash their hands before and after touching the client
Gown and gloves are worn by persons coming in contact with the wounds or infected equipment. Visitors should wash their hands before and after touching the client.
Question Number 12 of 20
A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements?
| | A) | In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice. |
| | B) | Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice. |
| | C) | Your family can use the same bathroom that you use without any special precautions. |
| | D) | Drink plenty of water and empty your bladder often during the initial 3 days of therapy. |
The correct answer is A: “In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice.”
The client''s urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours. The client should drink 3 to 4 liters a day for the initial 48 hours to help remove the agent from the body. Staff should limit contact with hospitalized clients to 30 minutes per day per person.
Question Number 13 of 20
Which approach is the best way to prevent infections when providing care to clients in the home setting?
| | A) | Handwashing before and after examination of clients |
| | B) | Wearing nonpowdered latex free gloves to examine the client |
| | C) | Using a barrier between the client's furniture and the nurse's bag |
| | D) | Wearing a mask with a shield during any eye/mouth/nose examination |
The correct answer is A: Handwashing
Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag. All of the options are correct. The sequence for priority actions would be options a, c, b, and d.
Question Number 14 of 20
During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches?
| | A) | Wash hands thoroughly before and after client contact |
| | B) | Wear gloves when in contact with body secretions |
| | C) | Double glove when in contact with feces or vomitus |
| | D) | Wear gloves when disposing of contaminated linens |
The correct answer is A: Wash hands thoroughly before and after client contact
Gram-negative bacilli cause Salmonella infection. Two million new cases appear each year. Lack of sanitation is the primary means of contamination. Thorough handwashing can prevent the spread of salmonella. Note that all of the options are correct actions. However, the primary action is to wash the hands.
Question Number 15 of 20
A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation?
| | A) | An infant who has been identified to have botulism |
| | B) | A toddler who ate a number of ibuprofen tablets |
| | C) | A preschooler who swallowed powdered plant food |
| | D) | A school aged child who took a handful of vitamins |
The correct answer is A: An infant who has been identified to have botulism
C. botulinum forms a toxin in improperly processed foods in anaerobic conditions. It is a neurotoxin that impairs autonomic and voluntary neurotransmission and causes muscular paralysis. Findings appear within 36 hours of ingestion. Be aware that all of the options may be candidates for gastric lavage or for activated charcoal administration
Question Number 16 of 20
After an explosion at a factory one of the workers approaches the nurse and says “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers?
| | A) | Get temperatures |
| | B) | Take blood pressure |
| | C) | Palpate pulses |
| | D) | Check alertness |
The correct answer is C: Palpate pulses
The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated, those clients would need to be seen first.
Question Number 17 of 20
Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?
| | A) | An infant with a postive culture of stool for Shigella |
| | B) | An elderly factory worker with a lab report that is positive for acid-fast bacillus smear |
| | C) | A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii |
| | D) | A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin |
The correct answer is B: An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time. Options a and d may need contact isolation precautions. Option c findings may indicate the initial stage of the autoimmune deficency syndrome (AIDS
Question Number 18 of 20
A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?
| | A) | grilled chicken sandwich and skim milk |
| | B) | roast beef, mashed potatoes, and green beans |
| | C) | peanut butter sandwich, banana, and iced tea |
| | D) | barbeque beef, baked beans, and cole slaw |
The correct answer is B: roast beef, mashed potatoes, and green beans
The client has correctly selected an appropriate lunch and appears to have knowledge of restrictions. Low granulocyte counts and susceptibility to infection are expected. Compromised host precautions require that foods are either cooked or canned. Options 1, 3 and 4 do not demonstrate learning, as raw fruits, vegetables, and milk are to be avoided
Question Number 19 of 20
Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency?
| | A) | An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal |
| | B) | A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago |
| | C) | An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis |
| | D) | A young adult in the second day of treatment for an overdose of acetometaphen |
The correct answer is D: A young adult in the second day of treatment for an overdose of acetometaphen
zthe correct answer is D. An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst oral treatement for as long. A risk of liver failure exists within this time period.
Question Number 20 of 20
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?
| | A) | Institute seizure precautions |
| | B) | Monitor neurologic status every hour |
| | C) | Place in respiratory/secretion precautions |
| | D) | Cefotaxime IV 50 mg/kg/day divided q6h |
The correct answer is C: Place in respiratory/secretion precautions
Meningococcal meningitis has the risk of being a bacterial infection. The initial therapeutic management of acute bacterial meningitis includes respiratory/secretions precautions, initiation of antimicrobial therapy, monitor neurological status along with vital signs, institute seizure precautions and lastly maintenance of optimum hydration. The first action is for nurses to take any necessary precautions to protect themselves and others from possible infection. Viral meningitis usually does not require protective measures of isolation.
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