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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A reason: An allergy bracelet provides immediate visual notification of the client's allergies to all healthcare personnel, which is crucial for preventing allergic reactions.

Choice B reason: Notifying the dietary department is important, but it does not have the same immediate impact on client safety as an allergy bracelet.

Choice C reason: Sending a list of medication allergies to the pharmacy is a necessary step, but it is secondary to providing immediate identification of the client's allergies.

Choice D reason: Placing a latex-free supply cart outside the room is a proactive measure to prevent exposure to latex, but the first step should be to ensure that the client's allergies are clearly identified for all staff.

A. Bowel incontinence. B. Impaired bed mobility. C. Fluid volume deficit. D. Caregiver role strain.

Correct Answer is C

Explanation

Choice A reason: While bowel incontinence is a concern, it does not pose an immediate threat to the client's physiological stability like fluid volume deficit does.

Choice B reason: Impaired bed mobility is important to address for long-term rehabilitation, but it is not the most immediate threat to life.

Choice C reason: Fluid volume deficit, especially due to diarrhea, can lead to dehydration and is a life-threatening condition that requires immediate intervention.

Choice D reason: Caregiver role strain is a significant issue but does not take precedence over the client's immediate physical health needs.

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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

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Correct Answer is C

Explanation

A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action 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?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

Exhibits

Chart Reviewed

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