1. A client newly diagnosed with tuberculosis (TB) is being admitted with a prescription for
"isolation precautions for tuberculosis." The nurse should
... [Show More] assign the client to which type
of room?
a. a semi-private room to implement droplet precautions
b. a private room to implement airborne precautions
c. a semi-private room to implement contact precautions
d. a private room to implement standard precautions
Rationale:
Isolation precautions for possible TB include implementing airborne precautions. The client
should be placed in a private room, and healthcare workers should wear fit-tested N95 or higher
level respirators to prevent transmission. Droplet precautions would be needed to prevent the
transmission of illness spread by coughing or sneezing and require the donning of a surgical
mask. Standard precautions are used with all clients. Contact precautions, which include gown
and gloves, are required to prevent the transmission of illness spread through contact.
2. The nurse has asked the unlicensed assistive personnel (UAP) to help with admitting an
elderly client who has been diagnosed with bacterial pneumonia. Which activity is
appropriate for the nurse to ask the UAP to perform?
a. Assess the client’s breath sounds.
b. Collect nursing history and assessment data.
c. Obtain the client’s height and weight.
d. Evaluate the client’s respiratory status.
Rationale:
It would be appropriate for the assistant to obtain the client’s weight and height.
It is the responsibility of the registered nurse to obtain the nursing history, assess the client’s
breath sounds, and evaluate the client’s respiratory status. Remember, don’t delegate what you
can EAT ( Evaluate, Assess, Teach).
3. Which mental status change may occur when a client with pneumonia is first
experiencing hypoxia?
a. coma
b. apathy
c. irritability
d. depression
Rationale:
Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or
anxiety as initial mental status changes. [Show Less]