The nurse is working on an infectious disease unit.
Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).

An older client with scabies who is admitted from an extended care facility.

Twin siblings admitted with scarlet fever that is complicated with pneumonia.

A female adolescent admitted with multiple genital Herpes simplex II lesions.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) is indicative of tuberculosis, an airborne disease. This client would require a room with negative airflow, use of a particulate respirator mask, and adherence to airborne as well as standard precautions.

Choice B rationale

Scabies is a skin infestation caused by a mite. It is transmitted through direct skin-to-skin contact and does not require airborne precautions.

Choice C rationale

Scarlet fever is a bacterial illness that often presents with a rash and is associated with strep throat. It is spread by direct contact with mucus, saliva, or skin sores of a person infected with the bacteria. It does not require airborne precautions.

Choice D rationale

Herpes simplex II lesions are typically sexually transmitted and do not require airborne precautions. Standard precautions would be sufficient.

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Correct Answer is D

Explanation

Choice A rationale

Applying ice, then a warm compress to the IV site may help with pain or inflammation, but it does not address the potential problem with the IV site itself. If the client is experiencing pain and refuses a flush to assess the site, it could indicate that the IV site is compromised.

Choice B rationale

Checking the medical record for the date of IV insertion could provide useful information about how long the IV has been in place, but it does not directly address the client’s current complaint of pain at the IV site.

Choice C rationale

Redressing the IV site while checking for redness could help identify signs of infection or inflammation, but it does not address the client’s complaint of pain or their refusal to have the site flushed.

Choice D rationale

Discontinuing the current IV site and inserting a new one is the most appropriate action in this situation. If the client is experiencing pain at the IV site and refuses a flush to assess the site, it suggests that the current IV site may be compromised. Inserting a new IV ensures that the client can continue to receive their scheduled IV medication safely.

A. Refer the client to the social worker for support therapy. B. Leave the client’s room and return later in the day. C. Explain that insulin is a life-saving drug for the client. D. Encourage the client to implement relaxation techniques.

Correct Answer is B

Explanation

Choice A rationale

While social workers can provide support therapy, they are not typically involved in teaching medical procedures like insulin injection15.

Choice B rationale

Leaving the room and returning later can give the client time to process the information and prepare for learning. It’s important to respect the client’s feelings and readiness to learn15.

Choice C rationale

While it’s true that insulin is a life-saving drug for people with type 1 diabetes, simply explaining this may not address the client’s fears or concerns about self-injection15.

Choice D rationale

Encouraging relaxation techniques can be helpful, but it doesn’t directly address the issue of teaching insulin injection15.

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The nurse is working on an infectious disease unit.Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.What should the nurse do next?

Correct Answer is D

Explanation

A client newly diagnosed with type 1 diabetes mellitus (DM) asks the nurse to leave the room when the nurse tries to teach self-administration of insulin injections.What should the nurse do next?

Correct Answer is B

Explanation

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea.Which source of contamination should the nurse consider when interviewing the client about exposure?

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis.Which expected outcome has the highest priority for this client?

What breakfast option should a nurse suggest for a 16-year-old patient suffering from diarrhea?

The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?

When educating a patient newly diagnosed with type 1 diabetes mellitus, the nurse explains that increased thirst is an early sign of Diabetic Ketoacidosis (DKA). What action should the nurse advise the patient to take if this sign of DKA appears?

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

The nurse is working on an infectious disease unit.
Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?