A nurse is assisting a charge nurse with room assignments.
There is one private room available on the unit to accommodate a client who needs airborne precautions.Which client should be assigned to this room?

A client who has community-acquired pneumonia with copious respiratory secretions

A client who has AIDS and is coughing up blood

A client who has Guillain-Barré syndrome and is on a ventilator

A client who has bronchitis and a tracheostomy

Answer and Explanation

The Correct Answer is A

Choice A rationale
A client who has community-acquired pneumonia with copious respiratory secretions should be assigned to the private room. This is because pneumonia, especially with copious respiratory secretions, can be transmitted through the air, and therefore requires airborne precautions.
Choice B rationale
A client who has AIDS and is coughing up blood may not necessarily require a private room for airborne precautions. While AIDS is a serious condition, it is not primarily transmitted through the air. Instead, it is transmitted through direct contact with bodily fluids, particularly blood, semen, vaginal fluids, and breast milk.
Choice C rationale
A client who has Guillain-Barré syndrome and is on a ventilator would not necessarily require a private room for airborne precautions. Guillain-Barré syndrome is a neurological disorder, not an infectious disease, and it is not transmitted from person to person.
Choice D rationale

A client who has bronchitis and a tracheostomy may not necessarily require a private room for airborne precautions. While bronchitis can be caused by an infection, it is typically transmitted through direct contact or droplet transmission, not through the air.

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Correct Answer is C

Explanation

Choice A rationale
Placing a 1-inch needle on the syringe is not appropriate for an intradermal injection such as a tuberculin skin test. Intradermal injections require a much shorter needle, typically 1/4 to 1/2 inch in length.
Choice B rationale
Holding the syringe at a 20° angle to the client’s skin is not correct for an intradermal injection. For an intradermal injection, the syringe should be held at a much shallower angle, typically about 5 to 15 degrees.
Choice C rationale

Drawing up 0.1 mL of purified protein derivative (PPD) from the vial is the correct action when preparing to administer a tuberculin skin test. This is the standard amount of PPD used for a tuberculin skin test.
Choice D rationale
Pinching the skin at the chosen site with the non-dominant hand before inserting the needle is not typically done for an intradermal injection. Instead, the skin is usually stretched taut to provide a flat surface for the injection.

A. Request a prescription for the insertion of an indwelling urinary catheter. B. Apply a moisture barrier ointment to the skin. C. Clean the skin and perineum with hot water after each episode of incontinence. D. Check the client’s skin every 8 hours for signs of breakdown. E. Check the client’s skin every 8 hours for signs of breakdown.

Correct Answer is B

Explanation

Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale

Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.

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A nurse is assisting a charge nurse with room assignments. There is one private room available on the unit to accommodate a client who needs airborne precautions.Which client should be assigned to this room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. What actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is caring for a client with urinary incontinence. What action should the nurse take to prevent skin breakdown?

Correct Answer is B

Explanation

A nurse is caring for a client whose hand movement is limited. What action should the nurse take to assist the client with feeding?

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A nurse is caring for a patient with pneumonia who has been on oxygen therapy for several days. Which of the following symptoms should the nurse recognize as a potential adverse effect of oxygen therapy?

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A nurse is assisting a charge nurse with room assignments.
There is one private room available on the unit to accommodate a client who needs airborne precautions.Which client should be assigned to this room?