A charge nurse is evaluating a newly licensed nurse's understanding of infection control procedures. Which of the following actions demonstrates that the nurse is following the appropriate protocol for a client who has streptococcal pharyngitis?

Explaining to the client that he cannot have visitors until his manifestations resolve

Wearing a mask when within 1 m (3.3 ft) of the client

Donning sterile gloves when performing routine oral care

Placing the client in a positive airflow room with 12 air exchanges per hour

Answer and Explanation

The Correct Answer is B

Rationale:
A. Restricting visitors is not necessary for streptococcal pharyngitis, as this infection is typically spread via droplets. Standard visitor precautions (masking and hand hygiene) are sufficient, rather than a total visitor ban.

B. Wearing a mask when within 1 meter (3.3 feet) of the client is appropriate for droplet precautions, which are indicated for streptococcal pharyngitis. The mask prevents inhalation of respiratory droplets that contain infectious bacteria. This action demonstrates correct adherence to infection control protocols.

C. Donning sterile gloves is unnecessary for routine oral care. Standard precautions using clean gloves are sufficient unless there is a risk of exposure to blood or body fluids requiring aseptic technique. Sterile gloves are reserved for invasive procedures or surgery.

D. Placing the client in a positive airflow room with 12 air exchanges per hour is part of airborne isolation for infections like tuberculosis. Streptococcal pharyngitis is not airborne, so this is not required.

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Correct Answer is C

Explanation

Rationale:
A. Suggesting participation in a community support group is beneficial for emotional support and disease management, but it is not the immediate priority for safety and health maintenance at home.

B. Setting up in-home physical therapy can support mobility and exercise tolerance but is secondary to ensuring the client’s environment is safe for daily living with COPD.

C. Requesting a referral for a home safety assessment is the priority because the client lives alone and has a new chronic respiratory condition. COPD can cause fatigue, shortness of breath, and limited mobility, increasing the risk of falls or injury at home. Ensuring a safe environment addresses immediate safety and prevents adverse events, which takes precedence over other interventions according to Maslow’s hierarchy of needs and nursing prioritization.

D. Providing printed materials for new prescriptions is important for medication adherence, but it does not address the immediate risk of harm in the home environment, making it a lower priority.

A. Development of 53 heart sounds B. Decreased brain natriuretic peptide levels C. Presence of jugular vein distention D. Increased weight of 2.27 kg (5 lb) in one week

Correct Answer is B

Explanation

Rationale:
A. The development of an S3 heart sound is a sign of ventricular dysfunction or fluid overload in heart failure. This would indicate worsening cardiac status rather than success of the quality improvement initiative.

B. Decreased brain natriuretic peptide (BNP) levels reflect improved cardiac function and reduced fluid overload. BNP is released in response to ventricular stretch, so lower levels indicate that heart failure is being better managed, which aligns with the goal of reducing readmissions. This is a positive outcome and demonstrates that the quality improvement initiative is effective.

C. Jugular vein distention (JVD) is a clinical sign of right-sided heart failure and fluid overload, indicating that the client’s heart failure is not optimally controlled. This finding would suggest the initiative may not be fully successful.

D. An increased weight of 2.27 kg (5 lb) in one week is an early indicator of fluid retention in heart failure. Rapid weight gain signals worsening volume overload, which would be a negative outcome and not indicative of success.

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A charge nurse is evaluating a newly licensed nurse's understanding of infection control procedures. Which of the following actions demonstrates that the nurse is following the appropriate protocol for a client who has streptococcal pharyngitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning discharge for a client who has a new diagnosis of COPD and lives alone. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

A nurse is assessing a client who has heart failure two months after the implementation of a quality improvement initiative to reduce the hospital readmission rate. Which of the following findings should the nurse identify as an indication the quality improvement initiative is successful?

Correct Answer is B

Explanation

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