Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following types of isolation precautions should the nurse initiate?
A. Protective environment.
Protective environment isolation precautions are used for immunocompromised patients to protect them from infections in the environment. It is not the appropriate precaution for a patient with bacterial meningitis, which is spread through respiratory droplets.
B. Airborne.
Airborne precautions are used for diseases that are spread through the air and require a negative pressure room. Examples include tuberculosis and chickenpox. Bacterial meningitis is spread through respiratory droplets, not airborne transmission.
C. Contact.
Contact precautions are used for diseases that are spread by direct or indirect contact. Examples include MRSA and Clostridium difficile. Bacterial meningitis is primarily spread through respiratory droplets, not direct contact.
D. Droplet.
Droplet precautions are used for diseases that are spread by respiratory droplets, such as influenza and bacterial meningitis. Patients with bacterial meningitis should be placed in a private room and wear a mask, and healthcare providers should wear a mask and eye protection when within 3 feet of the patient. This precaution helps prevent the spread of respiratory droplets containing the bacteria.
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Full Explanation
Choice A rationale:
Protective environment isolation precautions are used for immunocompromised patients to protect them from infections in the environment. It is not the appropriate precaution for a patient with bacterial meningitis, which is spread through respiratory droplets.
Choice B rationale:
Airborne precautions are used for diseases that are spread through the air and require a negative pressure room. Examples include tuberculosis and chickenpox. Bacterial meningitis is spread through respiratory droplets, not airborne transmission.
Choice C rationale:
Contact precautions are used for diseases that are spread by direct or indirect contact. Examples include MRSA and Clostridium difficile. Bacterial meningitis is primarily spread through respiratory droplets, not direct contact.
Choice D rationale:
Droplet precautions are used for diseases that are spread by respiratory droplets, such as influenza and bacterial meningitis. Patients with bacterial meningitis should be placed in a private room and wear a mask, and healthcare providers should wear a mask and eye protection when within 3 feet of the patient. This precaution helps prevent the spread of respiratory droplets containing the bacteria.
Similar Questions
A nurse is part of a task force planning to audit a facility's nursing units concerning adherence to hand-hygiene protocols.
Which of the following steps should the task force take first?
A. Take corrective measures to enforce hand hygiene.
Taking corrective measures to enforce hand hygiene should not be the first step. It is important to establish a baseline and understand the current situation through data collection and analysis before implementing corrective measures.
B. Establish methods for collecting data within the facility.
Establishing methods for collecting data within the facility is a crucial first step. Gathering information about the current hand hygiene practices, compliance rates, and areas of improvement is essential for the audit process. Data collection provides a factual basis for identifying problems and implementing targeted interventions.
C. Compare the facility's data with the established criteria for hand hygiene.
Comparing the facility's data with the established criteria for hand hygiene is a subsequent step after data collection. This step helps in evaluating the current practices against the accepted standards and guidelines. However, it is not the first step in the audit process.
D. Determine the accepted standards for hand hygiene.
Determining the accepted standards for hand hygiene is an essential first step. It involves researching and understanding the national and international guidelines, protocols, and recommendations related to hand hygiene. Knowing the standards helps the task force establish a benchmark against which the facility's practices can be evaluated. It provides a foundation for data collection and subsequent analysis.
Full Explanation
Choice A rationale:
Taking corrective measures to enforce hand hygiene should not be the first step. It is important to establish a baseline and understand the current situation through data collection and analysis before implementing corrective measures.
Choice B rationale:
Establishing methods for collecting data within the facility is a crucial first step. Gathering information about the current hand hygiene practices, compliance rates, and areas of improvement is essential for the audit process. Data collection provides a factual basis for identifying problems and implementing targeted interventions.
Choice C rationale:
Comparing the facility's data with the established criteria for hand hygiene is a subsequent step after data collection. This step helps in evaluating the current practices against the accepted standards and guidelines. However, it is not the first step in the audit process.
Choice D rationale:
Determining the accepted standards for hand hygiene is an essential first step. It involves researching and understanding the national and international guidelines, protocols, and recommendations related to hand hygiene. Knowing the standards helps the task force establish a benchmark against which the facility's practices can be evaluated. It provides a foundation for data collection and subsequent analysis.
A nurse is caring for a client who is in the latent phase of labor and reports severe back pain.
The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station.
Which of the following interventions should the nurse implement?
A. Administer a dose of terbutaline to the client.
Administering terbutaline is used to stop or slow down preterm labor contractions. In the given scenario, the client is in the latent phase of labor and is experiencing severe back pain. Terbutaline is not indicated for back pain during labor.
B. Place the client in a warm bath.
Placing the client in a warm bath can provide comfort and relaxation, but it may not specifically alleviate back pain during labor. Additionally, warm baths are more commonly used for pain relief in early labor or during the active phase, not specifically for back pain.
C. Apply counterpressure during each contraction.
Applying counterpressure during each contraction is an appropriate intervention for relieving back pain during labor. Back pain is a common discomfort experienced by many women during labor, and counterpressure, often applied by a support person or nurse, can help alleviate the discomfort. It is a non-pharmacological method that can be effective in managing pain during labor.
D. Request the provider prescribe a pudendal nerve block.
Requesting the provider prescribe a pudendal nerve block is not the first-line intervention for back pain during labor. Pudendal nerve blocks are used for pain relief during the second stage of labor (during delivery) and are typically administered by the provider if needed. It is not the appropriate intervention for back pain in the latent phase of labor.
Full Explanation
Choice A rationale:
Administering terbutaline is used to stop or slow down preterm labor contractions. In the given scenario, the client is in the latent phase of labor and is experiencing severe back pain. Terbutaline is not indicated for back pain during labor.
Choice B rationale:
Placing the client in a warm bath can provide comfort and relaxation, but it may not specifically alleviate back pain during labor. Additionally, warm baths are more commonly used for pain relief in early labor or during the active phase, not specifically for back pain.
Choice C rationale:
Applying counterpressure during each contraction is an appropriate intervention for relieving back pain during labor. Back pain is a common discomfort experienced by many women during labor, and counterpressure, often applied by a support person or nurse, can help alleviate the discomfort. It is a non-pharmacological method that can be effective in managing pain during labor.
Choice D rationale:
Requesting the provider prescribe a pudendal nerve block is not the first-line intervention for back pain during labor. Pudendal nerve blocks are used for pain relief during the second stage of labor (during delivery) and are typically administered by the provider if needed. It is not the appropriate intervention for back pain in the latent phase of labor.
A nurse is teaching a client who is at 20 weeks of gestation about how to manage heartburn.
Which of the following instructions should the nurse include?
A. "Lie down for 30 min after meals.”
Instructing the client to "Lie down for 30 min after meals" is an inappropriate recommendation for managing heartburn during pregnancy. Lying down after meals allows stomach acid from flowing back into the esophagus, worsening heartburn symptoms.
B. "Eat a high-fat snack at bedtime.”
Eating a high-fat snack at bedtime is not advisable for managing heartburn. Fatty foods can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus and worsen heartburn symptoms. Avoiding high-fat snacks close to bedtime is a more appropriate recommendation.
C. "Sip carbonated beverages throughout the day.”
Sipping carbonated beverages throughout the day can exacerbate heartburn symptoms. Carbonated beverages, including sodas and sparkling water, can increase stomach acid and contribute to heartburn. Therefore, advising the client to avoid carbonated beverages is more appropriate for managing heartburn during pregnancy.
D. "Drink hot herbal tea to relieve symptoms.”
Drinking hot herbal tea alleviates the heartburn symptoms and is recommended in pregnancy.
Full Explanation
Choice A rationale:
Instructing the client to "Lie down for 30 min after meals" is an inappropriate recommendation for managing heartburn during pregnancy. Lying down after meals allows stomach acid from flowing back into the esophagus, worsening heartburn symptoms.
Choice B rationale:
Eating a high-fat snack at bedtime is not advisable for managing heartburn. Fatty foods can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus and worsen heartburn symptoms. Avoiding high-fat snacks close to bedtime is a more appropriate recommendation.
Choice C rationale:
Sipping carbonated beverages throughout the day can exacerbate heartburn symptoms. Carbonated beverages, including sodas and sparkling water, can increase stomach acid and contribute to heartburn. Therefore, advising the client to avoid carbonated beverages is more appropriate for managing heartburn during pregnancy.
Choice D rationale:
Drinking hot herbal tea alleviates the heartburn symptoms and is recommended in pregnancy.