A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

A client who has pneumonia.

A client who has measles.

A client who has pertussis.

A client who has methicillin-resistant Staphylococcus aureus (MRSA).

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: A client who has measles.

Choice A rationale:

Airborne precautions are indicated for diseases that spread via small particles suspended in the air, such as droplets or dust particles that remain in the air for prolonged periods. Pneumonia is primarily spread through larger respiratory droplets and is not considered an airborne disease. Therefore, airborne precautions are not necessary for a client with pneumonia.

Choice B rationale:

Measles is a highly contagious airborne disease caused by the measles virus. It is transmitted through respiratory droplets and can remain in the air for an extended period. Initiating airborne precautions, such as wearing an N95 respirator mask and placing the client in a negative pressure isolation room, is crucial to prevent the spread of measles to healthcare workers and other patients.

Choice C rationale:

Pertussis (whooping cough) is primarily spread through respiratory droplets, similar to pneumonia. While it is a serious bacterial infection, it is not classified as an airborne disease. Thus, airborne precautions are not required for a client with pertussis.

Choice D rationale:

Methicillin-resistant Staphylococcus aureus (MRSA) is mainly spread through direct contact with contaminated surfaces or individuals. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air. Standard precautions, including wearing gloves and gowns, are typically sufficient when caring for a client with MRSA.

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Correct Answer is B

Explanation

The correct answer is choice B: "Support the client's feet with foot boots."

Choice A rationale:

Flexing the client's feet using pillows might not be sufficient to prevent foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, and using pillows alone may not provide adequate support to prevent this condition.

Choice B rationale:

Supporting the client's feet with foot boots is the most appropriate intervention to prevent foot drop due to immobility. Foot boots are specifically designed to hold the foot in a dorsiflexed position, preventing the calf muscles from tightening and causing foot drop.

Choice C rationale:

Placing a hand roll under the client's heels might offer some relief, but it's not the most effective intervention for preventing foot drop. Hand rolls are generally used to prevent footdrop by keeping the ankles in a neutral position, rather than solely supporting the heels.

Choice D rationale:

Removing ankle-foot orthotic devices at bedtime is not recommended if the client is at risk for developing foot drop. Ankle-foot orthotic devices are designed to provide continuous support to the feet and prevent muscle contractures. Removing them at bedtime could compromise the effectiveness of the intervention.

A. Client reports voiding three times during the night. B. Client reports burning and discomfort with urination. C. The client's WBC count is 11,000/mm². D. The client's output was 60 mL for the past 3 hr.

Correct Answer is D

Explanation

The correct answer is choice d. The client’s output was 60 mL for the past 3 hr.

Choice A rationale:

Voiding three times during the night (nocturia) is common in chronic kidney disease (CKD) due to the kidneys’ inability to concentrate urine. While it should be monitored, it is not the most urgent issue.

Choice B rationale:

Burning and discomfort with urination could indicate a urinary tract infection (UTI), which is important to address but not as immediately critical as low urine output.

Choice C rationale:

A WBC count of 11,000/mm² is slightly elevated and could indicate an infection or inflammation, but it is not as urgent as the low urine output.

Choice D rationale:

Low urine output (oliguria) of 60 mL over 3 hours is a critical finding in CKD patients. It indicates potential acute kidney injury or worsening kidney function, which requires immediate attention to prevent further complications.

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A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?

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A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first?

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?