A nurse is assisting with the admission of a client who
has active tuberculosis. Which of the following actions
should the nurse plan to take?
A.
... [Show More] Restrict the client's visitors to the immediate family.
B. Assign the client to a negative-pressure airflow
room.
C. Discard personal protective equipment outside the
client's room.
D. Have the client wear a HEPA mask during
transportation throughout the facility. - ...ANSWER...B.
Assign the client to a negative-pressure airflow room.
RATIONALE: The nurse should assign the client to a
negative-pressure airflow room to ensure that the air
from the client's room is not circulated throughout the
facility.
A nurse is assisting with the plan of care for a client
who has a bacterial infection and a persistent oral
temperature of 38.9° C (102° F). Which of the following
interventions should the nurse include in the plan of
care to treat the fever?
A. Administer acetaminophen.
B. Apply ice packs to the client's axillae.
C. Maintain the room temperature at 18.3° C (64.9° F).
D. Assist the client to ambulate four times a day. -
...ANSWER...A. Administer acetaminophen.
RATIONALE: The nurse should administer
acetaminophen or an NSAID such as ibuprofen to the
client to reduce the body's temperature. Acetaminophen
inhibits the synthesis of prostaglandins, resulting in a
reduced fever.
A nurse is contributing to the plan of care for a client
who has a positive throat culture for streptococci.
Which of the following interventions should the nurse
recommend to be included in the plan of care?
A. Place the client in a room with another client who
has pharyngitis.
B. Ensure that the client wears a surgical mask during
transportation throughout the facility.
C. Limit the client's visitors to visitations of 30 min.
D. Provide the client a room with negative-pressure
airflow of six air exchanges per hour. - ...ANSWER...B.
Ensure that the client wears a surgical mask during
transportation throughout the facility.
RATIONALE: Streptococcal pharyngitis requires droplet
precautions. The nurse should instruct the client to
wear a surgical mask when outside of the room to
prevent the spread of infection. Staff should make
every attempt to limit the client's movement outside of
the room.
A nurse is planning care for a client who is disoriented
and at risk for falls. Which of the following
interventions should the nurse include? (Select all that
apply.)
A. Ensure that the client is wearing nonskid slippers.
B. Move the bedside table away from the bedside.
C. Place the client in a room near the nurses' station.
D. Keep the bed's full side rails in the up position.
E. Reinforce teaching about how to use the call bell. -
...ANSWER...A. Ensure that the client is wearing nonskid
slippers.
Nonskid slippers provide better traction and can help
prevent slipping and falling.
C. Place the client in a room near the nurses' station.
Keeping the client close to the nurses' station allows
for more frequent observation to help identify actions
that increase the risk for falls.
E. Reinforce teaching about how to use the call bell.
Even if the client is confused, it is important to reinforce
the use of the call bell for assistance to help prevent
the client from attempting actions that could increase
the risk for falls.
A nurse is contributing to a plan of care for a client who
has a new prescription for a wrist restraint. Which of
the following actions should the nurse include in the
plan?
A. Check that the restraint is tied to a fixed frame of the
bed.
B. Pad bony prominences on the wrist. [Show Less]