Exhibits

Chart Reviewed

For each statement, click to indicate whether the statement is true or false.

Hand washing only needs to be performed when exiting the client’s room.

This client requires contact and droplet precautions.

A gown and gloves should be worn any time there is potential for contact with secretions.

A mask should always be worn when in the client’s room.

This client would require a private room if admitted.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.

Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it. Therefore, contact and droplet precautions are necessary.

Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.

Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.

Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.

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Correct Answer is B

Explanation

Choice A reason: Observing the color and amount of urine is important for assessing kidney function and hydration status but is not the most critical intervention for hypokalemia, which can have immediate life-threatening cardiac effects.

Choice B reason: Determining the apical pulse rate and rhythm is the most important intervention. Hypokalemia can lead to serious cardiac arrhythmias, and the apical pulse is the most accurate non-invasive way to assess cardiac rhythm and rate.

Choice C reason: Comparing muscle strength bilaterally is important for assessing the impact of hypokalemia on muscle function, but it is not as immediately life-threatening as cardiac effects.

Choice D reason: Assessing the strength of deep tendon reflexes can help evaluate neuromuscular involvement in hypokalemia but is less critical than monitoring for cardiac arrhythmias.

A. Shufling gait. B. Urinary incontinence. C. Syncope when bending. D. Hand tremors.

Correct Answer is ["A","C","D"]

Explanation

The correct answer isChoice A, Choice C, and Choice D.

Choice A rationale:A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.

Choice B rationale:Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.

Choice C rationale:Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.

Choice D rationale:Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.

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Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)

Correct Answer is B

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?

When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.

Exhibits

Chart Reviewed

For each statement, click to indicate whether the statement is true or false.