A nurse is caring for a client.

Nurses Notes: Day 1: Custom Nursing Assessment.

Vital Signs: Diagnostic Results: Client is admitted with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.

Prepare to administer an antibiotic to the client.

Which of the following actions should the nurse take? (Select all that apply.)

Encourage the client to increase fluid intake.

Place the client in a private room.

Place the client on contact precautions.

Wear a mask when caring for the client.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale
Encouraging the client to increase fluid intake is correct. Increasing fluid intake helps to maintain hydration, which is essential for the body to function properly, especially when the client is experiencing fever and muscle aches. Hydration helps to thin mucus, making it easier to expel, and supports the immune system in fighting off infection.
Choice B rationale
Placing the client in a private room is correct. A private room helps to prevent the spread of infection to other patients and healthcare workers. This is particularly important when the client has symptoms such as fever, sore throat, and fatigue, which could indicate a contagious illness.
Choice C rationale
Placing the client on contact precautions is incorrect. Contact precautions are typically used for infections that are spread by direct contact with the patient or their environment, such as MRSA or C. difficile. The symptoms described (headache, muscle aches, fever, sore throat, and fatigue) do not necessarily indicate an infection that requires contact precautions.
Choice D rationale
Wearing a mask when caring for the client is correct. Wearing a mask helps to prevent the transmission of respiratory infections, which can be spread through droplets when the client coughs or sneezes. This is especially important when the client has symptoms such as a sore throat and fever, which could indicate a respiratory infection.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale
Asking appropriate questions about suctioning indicates interest and understanding but does not demonstrate the ability to perform the procedure.
Choice B rationale
Performing the procedure independently shows that the partner has the necessary skills and confidence to care for the client at home.
Choice C rationale
Attending a class about tracheostomy care is beneficial but does not demonstrate the ability to perform the procedure independently.

Choice D rationale
Verbalizing all steps in the procedure indicates knowledge but does not demonstrate the practical ability to perform the procedure.

A. The SA node sends an electrical signal greater than 100/min. B. An early electrical signal occurs before the expected sinoatrial (SA) node signal. C. The heart’s electrical transmission through the atrioventricular (AV) node is unusually slow. D. The heart’s electrical signals are rapid, chaotic, and irregular.

Correct Answer is D

Explanation

Choice A rationale
The SA node sending an electrical signal greater than 100/min describes sinus tachycardia, not atrial fibrillation. In atrial fibrillation, the issue is not with the SA node but with the atria’s chaotic electrical activity.
Choice B rationale
An early electrical signal occurring before the expected SA node signal describes a premature atrial contraction (PAC), not atrial fibrillation. PACs are isolated events, whereas atrial fibrillation involves sustained irregular electrical activity.
Choice C rationale
Slow electrical transmission through the AV node describes a heart block, not atrial fibrillation. In atrial fibrillation, the problem is with the atria’s rapid and irregular electrical signals, not the AV node’s conduction speed.
Choice D rationale
Atrial fibrillation is characterized by rapid, chaotic, and irregular electrical signals in the atria. This leads to an irregular and often rapid heart rate, causing symptoms like dizziness and palpitations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a tracheostomy. The client’s partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client’s discharge?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has atrial fibrillation and reports dizziness and palpitations. Which of the following should the nurse understand is the cause of these manifestations?

Correct Answer is D

Explanation

A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath. Exhibits The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

A nurse is providing teaching about iron deficiency anemia to the parents of a toddler. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?