Fundamentals Of Nursing NCLEX Quiz 33

1. A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having a severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first?

Place the client on contact and airborne precautions.

Obtain blood. urine. and sputum for cultures.

Administer methylprednisolone (Solu-Medrol) 1 gram/IV.

Infuse normal saline at 100ml/hr.

Since SARS is a severe disease with a high mortality rate. the initial action should be to protect other clients and health care workers by placing the client in isolation. If an airborne-agent isolation (negative pressure) room is not available in the ED. droplet precautions should be initiated until the client can be moved to a negative-pressure room.Options B. C. and D: The other options should also be taken rapidly but are not as important as preventing transmission of the disease.

Explanation

Since SARS is a severe disease with a high mortality rate. the initial action should be to protect other clients and health care workers by placing the client in isolation. If an airborne-agent isolation (negative pressure) room is not available in the ED. droplet precautions should be initiated until the client can be moved to a negative-pressure room.Options B. C. and D: The other options should also be taken rapidly but are not as important as preventing transmission of the disease.

2. You are caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which of these nursing actions can you delegate to an LPN/LVN?

Obtain wound cultures during dressing changes.

Plan ways to improve the client’s oral protein intake.

Assess risk for further skin breakdown.

Educate the client about home care of the leg ulcer.

LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture.Options B. C. and D: Teaching. assessment. and planning of care are complex actions that should be carried out by a licensed nurse.

Explanation

LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture.Options B. C. and D: Teaching. assessment. and planning of care are complex actions that should be carried out by a licensed nurse.

3. Which action will you take to most effectively reduce the incidence of hospital-associated urinary tract infections?

Teach assistive personnel how to provide good perineal hygiene.

Ensure that clients have enough adequate fluid intake.

Limit the use of indwelling foley catheter (IFC).

Perform dipstick urinalysis for clients with risk factors for UTI.

The most effective way to reduce the incidence of UTIs in the hospital setting is to avoid using retention catheters.Options A. B. and D: These actions also reduce the risk for and/or detect UTI. but avoidance of indwelling catheter will be more effective.

Explanation

The most effective way to reduce the incidence of UTIs in the hospital setting is to avoid using retention catheters.Options A. B. and D: These actions also reduce the risk for and/or detect UTI. but avoidance of indwelling catheter will be more effective.

4. A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse delegated to an LPN/LVN?

Explaining the purpose of ordered stool cultures to the client and family.

Administering the ordered metronidazole (Flagyl) 500 mg PO to the client.

Reviewing the client’s medical history for any risk factors for diarrhea.

Performing ongoing assessments to determine the client’s hydration.

LPN/LVN education and scope of practice and education include the administration of medications.Options A. C. and D: Assessment of hydration status. client and family education. and assessment of risk factors for diarrhea should be done by a licensed nurse.

Explanation

LPN/LVN education and scope of practice and education include the administration of medications.Options A. C. and D: Assessment of hydration status. client and family education. and assessment of risk factors for diarrhea should be done by a licensed nurse.

5. A client comes to the outpatient clinic where you work complaining of abdominal pain. diarrhea. shortness of breath and epistaxis. Which of the following actions would you take first?

Ask the client about any recent travel to Asia or the Middle East.

Screening clients for upper respiratory tract symptoms.

Determine whether the client has had recommended immunizations.

Call an ambulance to take the client immediately to the hospital.

The client’s clinical manifestation suggest possible avian influenza (bird flu). If the client has traveled recently in Asia or the Middle East. where outbreaks of bird flu have occurred. you will need to institute airborne and contact precautions immediately.Options B. C. and D: The other actions may also be appropriate but are not the initial action to take for this client. who may transmit the infection to other clients or staff members.

Explanation

The client’s clinical manifestation suggest possible avian influenza (bird flu). If the client has traveled recently in Asia or the Middle East. where outbreaks of bird flu have occurred. you will need to institute airborne and contact precautions immediately.Options B. C. and D: The other actions may also be appropriate but are not the initial action to take for this client. who may transmit the infection to other clients or staff members.

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

A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C).

A client with diarrhea caused by C. difficile.

A client with a wound infected with VRE.

A client with a cough who may have Koch disease.

Clients with infections that require airborne precautions (such as TB) need to be in private rooms.Option A: Standard precautions are required for the client with toxic shock syndrome.Options B and C: Clients with infections that require contact precautions (such as C.difficile and VRE infections) should ideally be placed in private rooms; however. they can be placed in rooms with other clients with the same diagnosis.

Explanation

Clients with infections that require airborne precautions (such as TB) need to be in private rooms.Option A: Standard precautions are required for the client with toxic shock syndrome.Options B and C: Clients with infections that require contact precautions (such as C.difficile and VRE infections) should ideally be placed in private rooms; however. they can be placed in rooms with other clients with the same diagnosis.

7. You are caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infections?

A client who has a midline IV catheter in the left antecubital fossa.

A client with a peripherally inserted central catheter (PICC) line in the right upper arm.

A client with an implanted port in the right subclavian vein.

A client who has nontunneled central line in the left internal jugular vein.

Several factors increase the risk for infection for this client: central lines are associated with a higher infection risk. the skin of the neck and chest having a high number of microorganisms. and the line is tunneled.Options A and B: Peripherally inserted IV lines such as midline catheters and PICC line are associated with a lower incidence of infection.Option C: Implanted ports are placed under the skin and so are less likely to be associated with catheter infection than a nontunneled central IV line.

Explanation

Several factors increase the risk for infection for this client: central lines are associated with a higher infection risk. the skin of the neck and chest having a high number of microorganisms. and the line is tunneled.Options A and B: Peripherally inserted IV lines such as midline catheters and PICC line are associated with a lower incidence of infection.Option C: Implanted ports are placed under the skin and so are less likely to be associated with catheter infection than a nontunneled central IV line.

8. You are a school nurse. Which action will you take to have the most impact on the incidence of infectious disease in the school?

Ensure that students are immunized according to national guidelines.

Provide written information about infection control to all patients.

Make soap and water readily available in the classrooms.

Teach students how to cover their mouths when coughing.

The incidence of once common infectious diseases such as measles. chickenpox. and mumps has been most effectively reduced by immunization of all school-aged children.Options B. C. and D: The other options are also helpful but will not have as great as an impact as immunization.

Explanation

The incidence of once common infectious diseases such as measles. chickenpox. and mumps has been most effectively reduced by immunization of all school-aged children.Options B. C. and D: The other options are also helpful but will not have as great as an impact as immunization.

9. You are the pediatric unit charge nurse today and is working with a new RN. Which action by the new RN requires the most immediate action on your part?

The new RN places a child who has chemotherapy-induced neutropenia into a negative-pressure room.

The new RN wears goggles to change linens of a client who has diarrhea caused by C. difficile.

Clients who are neutropenic should be placed in positive-airflow rooms; placement of the child in a negative airflow room will increase the likelihood of infection for this client.Options A and D: The use of an N95 respirator is not necessary for pertussis. and goggles are not needed for changing the linens of clients infected with C. difficile; however. these protections do not increase the risk to the clients.Option C: Although private rooms are preferred for clients who need droplet precautions. such as client with RSV infection. they can be placed in rooms with other clients who are infected with the same microorganism.

Explanation

Clients who are neutropenic should be placed in positive-airflow rooms; placement of the child in a negative airflow room will increase the likelihood of infection for this client.Options A and D: The use of an N95 respirator is not necessary for pertussis. and goggles are not needed for changing the linens of clients infected with C. difficile; however. these protections do not increase the risk to the clients.Option C: Although private rooms are preferred for clients who need droplet precautions. such as client with RSV infection. they can be placed in rooms with other clients who are infected with the same microorganism.

10. While working in a pediatric clinic. you receive a telephone call from the parent of a 10-year-old who is receiving chemotherapy for leukemia. The client's sibling has chickenpox. Which of these actions will you anticipate taking next?

Teach the parents regarding contact and airborne precaution.

Administer varicella-zoster immune globulin to the client.

Prepare the client for admission to a private room in the hospital.

Educate the parent about the correct use of acyclovir (Zovirax).

Varicella-zoster immune globulin administration can prevent the development of chickenpox in high-risk clients and will typically be prescribed.Option A: Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child develops varicella.Options C and D: Hospitalization and acyclovir therapy may be required if the child develops a varicella-zoster virus infection.

Explanation

Varicella-zoster immune globulin administration can prevent the development of chickenpox in high-risk clients and will typically be prescribed.Option A: Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child develops varicella.Options C and D: Hospitalization and acyclovir therapy may be required if the child develops a varicella-zoster virus infection.