A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

Place the client in a room with negative airflow.

Wear a gown when providing care to the client.

Ensure the client's room has HEPA filtration.

Wear a mask when providing care to the client.

Answer and Explanation

The Correct Answer is D

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

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Correct Answer is B

Explanation

A. Checking the instrument gauge to ensure it starts at zero is important for accurate readings.

B. Placing the arm above the level of the heart can result in a falsely low blood pressure reading. The arm should be at the level of the heart for an accurate measurement.

C. Wrapping the cuff snugly around the arm ensures a proper fit, which is necessary for accurate readings.

D. The bladder of the cuff should be centered over the brachial artery to obtain the most accurate reading.

A. Wheezes B. Rhonchi C. Crackles D. Stridor

Correct Answer is A

Explanation

A. Wheezes are high-pitched continuous sounds heard during exhalation, commonly associated with asthma due to narrowed airways.

B. Rhonchi are low-pitched sounds caused by airflow obstruction in the larger airways and typically clear with coughing.

C. Crackles (or rales) are high-pitched sounds heard during inhalation and are often associated with fluid in the lungs, such as in pneumonia or heart failure.

D. Stridor is a high-pitched sound heard during inspiration and is often indicative of upper airway obstruction.

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A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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