A nurse is educating a client who is under protective isolation precautions. Which statement from the client indicates they have understood the teaching?

“I can shower up to three times a week.”.

“I will inform my friends and family to visit when I’m feeling well.”.

“I can take a plane to visit my grandchildren.”.

“I will wear a face mask when leaving my hospital room.”.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While showering frequency can vary depending on the specific isolation precautions, it does not indicate understanding of the protective isolation precautions.

Choice B rationale

Informing friends and family to visit when feeling well does not indicate understanding of protective isolation precautions. Protective isolation precautions are designed to protect the patient from infections, not based on how the patient is feeling.

Choice C rationale

Taking a plane to visit grandchildren does not indicate understanding of protective isolation precautions. Travel restrictions would depend on the specific condition and doctor’s advice.

Choice D rationale

Wearing a face mask when leaving the hospital room is a common requirement in protective isolation precautions to prevent the spread of infections.

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Correct Answer is C

Explanation

Choice A rationale

Touching the patient’s face with a cotton ball is not part of the Romberg test. This action is more commonly associated with tests of facial sensation.

Choice B rationale

Applying a vibrating tuning fork to the patient’s forehead is not part of the Romberg test. This action is more commonly associated with tests of vibratory sensation.

Choice C rationale

Having the patient stand with their arms at their sides and their feet together is the correct method for conducting a Romberg test.

Choice D rationale

Performing direct percussion over the area of the kidneys is not part of the Romberg test. This action is more commonly associated with tests of kidney function or the presence of kidney disease.

A. Ask another nurse to observe the medication wastage. B. Notify the pharmacy when wasting the medication. C. Lock the remaining medication in the controlled substances cabinet. D. Dispose of the vial with the remaining medication in a sharps container.

Correct Answer is A

Explanation

Choice A rationale

After drawing up the medication, the nurse should ask another nurse to observe the medication wastage. This is a standard procedure for controlled substances like opioids. The second nurse acts as a witness to ensure that the unused portion of the medication is disposed of properly and not diverted for inappropriate use.

Choice B rationale

Notifying the pharmacy when wasting the medication is not the immediate next step after drawing up the medication. While some institutions may require notification of the pharmacy for controlled substance wastage, the immediate next step is typically to have another nurse witness the wastage.

Choice C rationale

Locking the remaining medication in the controlled substances cabinet is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

Choice D rationale

Disposing of the vial with the remaining medication in a sharps container is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

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A nurse is educating a client who is under protective isolation precautions. Which statement from the client indicates they have understood the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

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