Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client?
A. The client should wear a gown during transport.
The client wearing a gown during transport is not typically necessary for droplet precautions unless there is a risk of the gown becoming contaminated with infectious material. Gowns are primarily used to protect the healthcare worker or other patients if there is direct contact with the patient.
B. The nurse should wear a mask during transport.
While the nurse should wear a mask if they will be within close proximity to the client, the primary concern in droplet precautions is to prevent the spread of infection from the client, who is the source of the droplets.
C. The client should wear a mask during transport.
The client should wear a mask during transport to contain respiratory secretions and minimize the risk of droplet spread, as droplets can be disseminated by coughing, sneezing, or talking. This is a key component of source control in droplet precautions. In summary, the primary goal of droplet precautions is to prevent the spread of infections through large respiratory droplets that are expelled by the client. Therefore, having the client wear a mask is the most effective measure among the options provided to reduce the risk of transmission during transport.
D. The nurse should wear a gown during transport.
Similar to choice A, the nurse wearing a gown during transport is not a standard requirement for droplet precautions unless there is anticipated contact with the patient or their environment that might result in contamination.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The client should wear a mask during transport to prevent the spread of infectious droplets. The nurse should wear appropriate personal protective equipment (PPE) based on the precautions required for the specific client, which in this case would be a mask. The nurse does not need to wear a gown as droplet precautions do not require the use of a gown during transport.
The correct answer is choice C, the client should wear a mask during transport.
Choice A rationale:
The client wearing a gown during transport is not typically necessary for droplet precautions unless there is a risk of the gown becoming contaminated with infectious material. Gowns are primarily used to protect the healthcare worker or other patients if there is direct contact with the patient.
Choice B rationale:
While the nurse should wear a mask if they will be within close proximity to the client, the primary concern in droplet precautions is to prevent the spread of infection from the client, who is the source of the droplets.
Choice C rationale:
The client should wear a mask during transport to contain respiratory secretions and minimize the risk of droplet spread, as droplets can be disseminated by coughing, sneezing, or talking. This is a key component of source control in droplet precautions.
Choice D rationale:
Similar to choice A, the nurse wearing a gown during transport is not a standard requirement for droplet precautions unless there is anticipated contact with the patient or their environment that might result in contamination.
In summary, the primary goal of droplet precautions is to prevent the spread of infections through large respiratory droplets that are expelled by the client. Therefore, having the client wear a mask is the most effective measure among the options provided to reduce the risk of transmission during transport.
Similar Questions
A nurse is reinforcing teaching with a client about heart disease prevention. Which of the following client statements indicates an understanding of the teaching?
A. "I will increase my dairy intake by drinking whole milk with every meal."
Increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heart disease, so this is not the correct statement.
B. "I will improve my LDL cholesterol by raising it from 100 to 130."
This is incorrect because lowering, not raising, LDL cholesterol is essential in preventing heart disease.
C. "I will exercise by walking twice a week for 25 minutes."
This is incorrect because exercising only twice a week for 25 minutes is not enough to prevent heart disease.
D. "I will try to maintain my blood pressure around 116/72."
"I will try to maintain my blood pressure around 116/72." This is because maintaining blood pressure within a normal range can help prevent heart disease. Choice A is incorrect because increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heartdisease.
Full Explanation
"I will try to maintain my blood pressure around 116/72." This is because maintaining blood pressure within a normal range can help prevent heart disease. Choice A is incorrect because increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heart disease.
Choice B is incorrect because lowering, not raising, LDL cholesterol is essential in preventing heart disease.
Choice C is incorrect because exercising only twice a week for 25 minutes is not enough to prevent heart disease.
An explanation for why the other choices are not answers: A – Increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heart disease, so this is not the correct statement. B – Lowering, not raising, LDL cholesterol is essential in preventing heart disease, so this is not the correct statement. C – Exercising only twice a week for 25 minutes is not enough to prevent heart disease. Thus, this is not the correct statement.
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
A. Perform suctioning.
The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles. Other choices:
B. Instill saline into the tubing.
Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.
C. Check the cuff pressure.
Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.
D. Increase the humidification.
Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.
Full Explanation
The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.
Other choices:
Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.
Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.
Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.
A nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing?
A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter
Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.
B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter
Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.
C. Tenderness at the injection site
Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.
D. Palpable area of induration, greater than 10 mm (0.4 in) in diameter
Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease. The other choices are not correct because:
Full Explanation
Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.
The other choices are not correct because:
- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.
- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.
- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.