A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?

Droplet precautions

Airborne precautions

Protective environment

Contact precautions

Answer and Explanation

The Correct Answer is D

Herpes simplex is primarily transmitted through direct contact with the skin or mucous membranes of an infected individual. Contact precautions are designed to prevent the spread of microorganisms that are transmitted by direct contact or indirect contact with contaminated surfaces. These precautions include wearing gloves and a gown when entering the client's room, ensuring proper hand hygiene, and using dedicated equipment for the client.

Droplet precautions are used for infections that are transmitted through respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis.

Airborne precautions are used for infections that are transmitted by smaller droplet nuclei that can remain suspended in the air for longer periods, such as tuberculosis or measles.

Protective environment is a specialized isolation precaution used for clients with compromised immune systems, such as those undergoing stem cell transplantation, and involves strict control of the environment to reduce the risk of acquiring infections.

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Correct Answer is A

Explanation

When administering eye drops to a child, the nurse should apply gentle pressure to the lacrimal punctum (the small opening in the inner corner of the eye) after administering the drops. This can help prevent the medication from draining into the tear duct and being absorbed into the bloodstream, which can reduce systemic side eﬀects.

A. Ecchymosis on the inner left thigh B. One fingerbreadth of space between the cast and the skin C. Diminished pulses on the aﬀected extremity D. Client report of muscle spasms of the left leg

Correct Answer is C

Explanation

c. Diminished pulses on the aﬀected extremity. This finding may indicate compromised circulation, which is

a serious complication that requires immediate intervention.

Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.

Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.

Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may

be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the aﬀected extremity.

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A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

Correct Answer is C

Explanation

A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client. Laboratory Results Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is assisting with the care of a client. Laboratory Results Abdominal ultrasound: mass present in small intestine proximal to the ileocecal valve. The size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching?

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