Four clients with infections arrive at the emergency department with some existing infection, however, only one private room is available. Which of the following clients is the most appropriate to assign to the private room?

A client with diarrhea after taking antibiotics for 10 days for a UTI

A client with abdominal pain and a temperature of 102.4°F (39.1°C)

A client with a productive cough that is blood tinged

A client with a wound infection and draining pus-like drainage

Answer and Explanation

The Correct Answer is C

A reason:

A client with diarrhea after taking antibiotics for 10 days for a UTI is not the most appropriate to assign to a private room. While this client may have an infection, diarrhea alone does not typically warrant isolation over other more contagious conditions.

B reason:

A client with abdominal pain and a fever may have an infection, but without more specific symptoms indicating a highly contagious disease, this client does not necessarily require a private room over others with more concerning symptoms.

C reason:

A client with a productive cough that is blood tinged is the most appropriate to assign to the private room. This client could have a highly contagious respiratory infection such as tuberculosis, which requires isolation to prevent the spread of infection to others in the hospital.

D reason:

A client with a wound infection and draining pus-like drainage needs careful management to prevent cross-contamination, but respiratory infections typically take precedence for private rooms due to their high contagion potential.

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Correct Answer is B

Explanation

A reason:

Using a stiff toothbrush is incorrect because it can cause gum irritation and damage. A soft-bristled toothbrush is recommended for effective and gentle cleaning.

B reason:

Turning the client on his side before starting oral care is correct. This position helps prevent aspiration, especially in immobile clients who may have difficulty swallowing or clearing their airway.

C reason:

Applying petroleum jelly to the client's lips after oral care is not the primary action. While moisturizing the lips can be part of oral care, it is secondary to ensuring safe and effective cleaning.

D reason:

Using the thumb and index finger to keep the client's mouth open is unsafe. An oral care sponge or bite block should be used to prevent injury to the nurse or the client.

A. When walking, move your left foot forward first. B. Keep your elbow straight when you hold the cane. C. Move the cane forward 18 inches with each step. D. Hold the cane with your left hand.

Correct Answer is A

Explanation

A reason:

When walking, moving the left foot forward first is correct. For clients with left-sided weakness, the cane should be used to provide support for the weak side. Moving the left foot first while using the cane helps maintain balance and stability.

B reason:

Keeping the elbow straight when holding the cane is incorrect. The elbow should be slightly bent when holding the cane to allow for better control and shock absorption, reducing strain on the arm.

C reason:

Moving the cane forward 18 inches with each step is incorrect. The cane should be moved a comfortable distance forward, typically about 6 to 12 inches, to maintain stability and support without overreaching.

D reason:

Holding the cane with the left hand is incorrect. For left-sided weakness, the cane should be held in the right hand to provide support and balance on the opposite side of the weakness.

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Four clients with infections arrive at the emergency department with some existing infection, however, only one private room is available. Which of the following clients is the most appropriate to assign to the private room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1°C (98.8°F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

The nurse is preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items should the nurse plan to use? (Select all that apply.)

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

The nurse is caring for a client who presented to the emergency room with BP of 138/90, HR of 110, O2 Sat of 95%, Temp of 38°C, and abdominal pain level of 7/10. Which of the above vital signs would the nurse address first?

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?