Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
A. Initiate contact precautions for the client upon admission
This is incorrect because contact precautions are not sufficient to prevent the spread of TB, which is an airborne disease that can travel through small droplets in the air.
B. Restrict visitors from entering the client's room during hospitalization
This is incorrect because visitors can enter the client's room as long as they wear appropriate personal protective equipment (PPE) such as an N95 respirator, gown, gloves, and eye protection.
C. Wear a surgical mask while providing care for the client
This is incorrect because a surgical mask does not filter out small airborne particles that carry TB bacteria. The nurse should wear an N95 respirator or higher level of respiratory protection when caring for a client who has active TB.
D. Have the client wear a surgical mask while being transported outside the room
This is correct because a surgical mask can reduce the amount of droplets that are expelled by the client when coughing or sneezing, thus minimizing the risk of infecting others in common areas or hallways.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
Have the client wear a surgical mask while being transported outside the room.
- A. Initiate contact precautions for the client upon admission. This is incorrect because contact precautions are not sufficient to prevent the spread of TB, which is an airborne disease that can travel through small droplets in the air.
- B. Restrict visitors from entering the client's room during hospitalization. This is incorrect because visitors can enter the client's room as long as they wear appropriate personal protective equipment (PPE) such as an N95 respirator, gown, gloves, and eye protection.
- C. Wear a surgical mask while providing care for the client. This is incorrect because a surgical mask does not filter out small airborne particles that carry TB bacteria. The nurse should wear an N95 respirator or higher level of respiratory protection when caring for a client who has active TB.
- D. Have the client wear a surgical mask while being transported outside the room. This is correct because a surgical mask can reduce the amount of droplets that are expelled by the client when coughing or sneezing, thus minimizing the risk of infecting others in common areas or hallways.
Similar Questions
A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?
A. A 6-month-old infant who has croup and an O2 saturation of 92% on room air
While croup can be serious, an O2 saturation of 92% on room air is generally stable. This child's condition is concerning but not immediately life-threatening.
B. A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication
A 15-year-old adolescent who is 2 hours postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication is in need of comfort measures. Postoperative pain management is important for recovery, but it is not a priority over more critical conditions.
C. A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr
A 3-year-old toddler with gastroenteritis, moderate dehydration, and two loose bowel movements over the past 24 hours requires rehydration and monitoring. The normal range for bowel movements varies, but two loose stools in 24 hours for a toddler with gastroenteritis is not unusual. Dehydration can become severe, so this child should be assessed soon, but it is not the most urgent case.
D. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
This child's sudden relief from pain could be a sign of a perforated appendix, a serious complication that requires immediate medical attention. Therefore, this child's condition is the most urgent and requires immediate assessment.
E. None
None
F. None
None
Full Explanation
The correct answer is D
Choice A Reason: While croup can be serious, an O2 saturation of 92% on room air is generally stable. This child's condition is concerning but not immediately life-threatening.
Choice B Reason: A 15-year-old adolescent who is 2 hours postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication is in need of comfort measures. Postoperative pain management is important for recovery, but it is not a priority over more critical conditions.
Choice C Reason: A 3-year-old toddler with gastroenteritis, moderate dehydration, and two loose bowel movements over the past 24 hours requires rehydration and monitoring. The normal range for bowel movements varies, but two loose stools in 24 hours for a toddler with gastroenteritis is not unusual. Dehydration can become severe, so this child should be assessed soon, but it is not the most urgent case.
Choice D Reason: This child's sudden relief from pain could be a sign of a perforated appendix, a serious complication that requires immediate medical attention. Therefore, this child's condition is the most urgent and requires immediate assessment.
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?
A. Radial vein of the inner arm
This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.
B. Great saphenous vein of the leg
This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.
C. Dorsal plexus vein of the foot
This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.
D. Basilic vein of the hand
This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.
Full Explanation
- A. Radial vein of the inner arm. This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.
- B. Great saphenous vein of the leg. This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.
- C. Dorsal plexus vein of the foot. This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.
- D. Basilic vein of the hand. This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.
A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
A. A client who is receiving verapamil and has a continuous infusion of total parenteral nutrition (TPN)
This choice is incorrect because verapamil and TPN do not have a significant food and medication interaction. Verapamil is a calcium channel blocker that can lower blood pressure and heart rate, while TPN is a form of intravenous nutrition that provides calories, electrolytes, vitamins, and minerals. The nurse should monitor the client's vital signs and blood glucose levels, but there is no need to intervene to prevent an interaction.
B. A client who is taking phenytoin and is requesting a milkshake
This choice is incorrect because phenytoin and milkshakes do not have a significant food and medication interaction. Phenytoin is an anticonvulsant that can decrease the absorption of some vitamins, such as folic acid and vitamin D, but milkshakes are not a major source of these nutrients. The nurse should encourage the client to eat a balanced diet and take supplements as prescribed, but there is no need to intervene to prevent an interaction.
C. A client who is receiving a diet high in potassium-rich foods and furosemide by mouth
This choice is incorrect because potassium-rich foods and furosemide do not have a significant food and medication interaction. Furosemide is a loop diuretic that can cause hypokalemia, or low potassium levels, but potassium-rich foods can help prevent this complication. The nurse should monitor the client's electrolyte levels and fluid balance, but there is no need to intervene to prevent an interaction.
D. A client who is receiving an MAOI and is requesting a cheeseburger for dinner
This choice is correct because MAOIs and cheeseburgers have a significant food and medication interaction. MAOIs are antidepressants that can cause hypertensive crisis, or dangerously high blood pressure, if the client consumes foods that contain tyramine, such as aged cheeses, cured meats, fermented foods, and beer. The nurse should intervene to prevent the client from eating a cheeseburger and educate the client about avoiding tyramine-containing foods while taking MAOIs.
Full Explanation
- A. This choice is incorrect because verapamil and TPN do not have a significant food and medication interaction. Verapamil is a calcium channel blocker that can lower blood pressure and heart rate, while TPN is a form of intravenous nutrition that provides calories, electrolytes, vitamins, and minerals. The nurse should monitor the client's vital signs and blood glucose levels, but there is no need to intervene to prevent an interaction.
- B. This choice is incorrect because phenytoin and milkshakes do not have a significant food and medication interaction. Phenytoin is an anticonvulsant that can decrease the absorption of some vitamins, such as folic acid and vitamin D, but milkshakes are not a major source of these nutrients. The nurse should encourage the client to eat a balanced diet and take supplements as prescribed, but there is no need to intervene to prevent an interaction.
- C. This choice is incorrect because potassium-rich foods and furosemide do not have a significant food and medication interaction. Furosemide is a loop diuretic that can cause hypokalemia, or low potassium levels, but potassium-rich foods can help prevent this complication. The nurse should monitor the client's electrolyte levels and fluid balance, but there is no need to intervene to prevent an interaction.
- D. This choice is correct because MAOIs and cheeseburgers have a significant food and medication interaction. MAOIs are antidepressants that can cause hypertensive crisis, or dangerously high blood pressure, if the client consumes foods that contain tyramine, such as aged cheeses, cured meats, fermented foods, and beer. The nurse should intervene to prevent the client from eating a cheeseburger and educate the client about avoiding tyramine-containing foods while taking MAOIs.