A nurse is caring for a client in the intensive care unit.

Exhibits

The nurse is reviewing the admission assessment, nurses' notes, vital signs, and laboratory results. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies that the client's and can indicate the development of delirium.

illusions

past medical history

hallucinations

changes in orientation

Answer and Explanation

Correct Answer : C,D

A. illusions aren’t common in delirium

B. the client’s past medical history isn’t indicative of delirium.

C. Delirium can manifest as disorientation, confusion, agitation, restlessness, illusions, or hallucinations. It can also impair memory, judgment, and language.

D. Delirium can manifest as disorientation, confusion, agitation, restlessness, illusions, or hallucinations. It can also impair memory, judgment, and language.

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Correct Answer is C

Explanation

A. Varicella-zoster requires airborne and contact precautions due to the highly contagious nature of chickenpox (varicella) and shingles (zoster).

B. Vancomycin-resistant enterococcus (VRE) typically requires contact precautions to prevent transmission.

C. Pertussis is spread via respiratory droplets, so droplet precautions are necessary to prevent transmission.

D. Rotavirus is transmitted via the fecal-oral route and typically requires contact precautions.

A. Wear an N95 respirator. B. Insert an indwelling urinary catheter to monitor urinary output. C. Monitor the client's vital signs every 8 hr. D. Use a dedicated stethoscope.

Correct Answer is D

Explanation

A. Wearing an N95 respirator is not necessary when caring for a client with neutropenia due to HIV unless the client has respiratory symptoms or is undergoing procedures that generate aerosols.

B. Inserting an indwelling urinary catheter should be avoided unless necessary, as it can

introduce the risk of infection, which is particularly concerning in clients with neutropenia.

C. Monitoring vital signs every 8 hours may not provide sufficient frequency for detecting changes in a client with neutropenia who may be at risk for rapid deterioration.

D. Using a dedicated stethoscope helps prevent the spread of infection to other clients by avoiding cross-contamination, which is especially important when caring for a client with neutropenia who is at increased risk of infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

Correct Answer is C

Explanation

A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

Correct Answer is D

Explanation

A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client.Which of the following is the safest site for the nurse to use?

A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?

A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hours old. The nurse should plan to notify the provider of which of the following findings?

A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?

A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?

A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome?