Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. Restrict the client's visitors to the immediate family.
Restrict the client's visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosismay need to wear masks in certain situations.
B. Assign the client to a negative pressure airflow room.
Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility.
C. Discard personal protective equipment outside the client's room.
Discard personal protective equipment outside the client's room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client's room and properly disposing of it afterward. The nurse should follow standard precautions for infection control.
D. Have the client wear a HEPA mask during transportation throughout the facility.
Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.
This question is an excerpt from Nurse Dive's nursing test bank - LPN ATI fundamental proctored exam. Take the full exam now
Full Explanation
A. Restrict the client's visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosis
may need to wear masks in certain situations.
B. Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility.
C. Discard personal protective equipment outside the client's room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client's room and properly disposing of it afterward. The nurse should follow standard precautions for infection control.
D. Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.
Similar Questions
A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?
A. Administer an analgesic 30 min before starting the procedure.
Administer an analgesic 30 min before starting the procedure: Correct. Before performing wound irrigation, it is essential to provide pain relief to the client. Administering an analgesic 30 minutes before the procedure will help manage pain during wound irrigation.
B. Hold the syringe 5 cm (2 in) above the upper end of the wound.
Hold the syringe 5 cm (2 in) above the upper end of the wound: This action does not contribute to proper wound irrigation. The nurse should direct the irrigation solution to the wound site to cleanse it effectively.
C. Place the irrigation solution in a basin of cool water.
Place the irrigation solution in a basin of cool water: Using cool water is not the best practice for wound irrigation. The irrigation solution should be at room temperature or a temperature specified by the healthcare provider.
D. Perform the wound irrigation with a 10mL syringe with an angiocatheter.
Perform the wound irrigation with a 10mL syringe with an angiocatheter: Wound irrigation typically requires a larger volume of fluid to adequately cleanse the wound. A 10mL syringe may not be sufficient, and using an angiocatheter is not appropriate for wound irrigation. A larger syringe or irrigation solution bag with an appropriate wound irrigation tool is usually used.
Full Explanation
A. Administer an analgesic 30 min before starting the procedure: Correct. Before performing wound irrigation, it is essential to provide pain relief to the client. Administering an analgesic 30 minutes before the procedure will help manage pain during wound irrigation.
B. Hold the syringe 5 cm (2 in) above the upper end of the wound: This action does not contribute to proper wound irrigation. The nurse should direct the irrigation solution to the wound site to cleanse it effectively.
C. Place the irrigation solution in a basin of cool water: Using cool water is not the best practice for wound irrigation. The irrigation solution should be at room temperature or a temperature specified by the healthcare provider.
D. Perform the wound irrigation with a 10mL syringe with an angiocatheter: Wound irrigation typically requires a larger volume of fluid to adequately cleanse the wound. A 10mL syringe may not be sufficient, and using an angiocatheter is not appropriate for wound irrigation. A larger syringe or irrigation solution bag with an appropriate wound irrigation tool is usually used.
A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes?
A. Body regulation of heat and cold increases with age.
Body regulation of heat and cold increases with age: This statement is incorrect. Age-related changes can lead to decreased efficiency in regulating body temperature, making older adults more susceptible to extreme temperatures.
B. Circulation becomes less efficient with age.
Circulation becomes less efficient with age: Correct. With age, blood vessels can lose some of their elasticity, leading to decreased efficiency in circulating blood throughout the body. This can impact the ability to respond to temperature changes effectively.
C. Increased metabolic rate occurs with age, and increasing body temperature.
Increased metabolic rate occurs with age, and increasing body temperature: This statement is incorrect. In general, metabolic rate tends to decrease with age, which can contribute to decreased heat production in older adults.
D. Sweat gland activity is increased with age.
Sweat gland activity is increased with age: This statement is incorrect. Sweat gland activity tends to decrease with age, leading to decreased sweating and potential challenges in cooling the body during hot conditions.
Full Explanation
A. Body regulation of heat and cold increases with age: This statement is incorrect. Age-related changes can lead to decreased efficiency in regulating body temperature, making older adults more susceptible to extreme temperatures.
B. Circulation becomes less efficient with age: Correct. With age, blood vessels can lose some of their elasticity, leading to decreased efficiency in circulating blood throughout the body. This can impact the ability to respond to temperature changes effectively.
C. Increased metabolic rate occurs with age, and increasing body temperature: This statement is incorrect. In general, metabolic rate tends to decrease with age, which can contribute to decreased heat production in older adults.
D. Sweat gland activity is increased with age: This statement is incorrect. Sweat gland activity tends to decrease with age, leading to decreased sweating and potential challenges in cooling the body during hot conditions.
A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include?
A. "Keep your knees in a locked position when standing for prolonged periods."
"Keep your knees in a locked position when standing for prolonged periods." This instruction is incorrect. Keeping knees locked can lead to muscle fatigue and increased risk of injury during prolonged standing.
B. "Bend at the waist when lifting a heavy object."
"Bend at the waist when lifting a heavy object." This instruction is incorrect. Bending at the waist during lifting can strain the lower back and increase the risk of back injuries.
C. "Keep your feet close together when lifting a heavy object."
"Keep your feet close together when lifting a heavy object." This instruction is incorrect.Keeping feet close together can make the base unstable and increase the risk of falling or losing balance during lifting.
D. "When lifting a heavy object, keep it close to your body."
"When lifting a heavy object, keep it close to your body." Correct. Keeping the heavy object close to the body while lifting helps reduce strain on the back and minimizes the risk of injury. This technique allows the body's core muscles to better support the weight.
Full Explanation
A. "Keep your knees in a locked position when standing for prolonged periods." This instruction is incorrect. Keeping knees locked can lead to muscle fatigue and increased risk of injury during prolonged standing.
B. "Bend at the waist when lifting a heavy object." This instruction is incorrect. Bending at the waist during lifting can strain the lower back and increase the risk of back injuries.
C. "Keep your feet close together when lifting a heavy object." This instruction is incorrect.
Keeping feet close together can make the base unstable and increase the risk of falling or losing balance during lifting.
D. "When lifting a heavy object, keep it close to your body." Correct. Keeping the heavy object close to the body while lifting helps reduce strain on the back and minimizes the risk of injury. This technique allows the body's core muscles to better support the weight.