When using standard precautions, the nurse knows that standard precautions mandate what?

Rinsing gloves that become visibly soiled during use.

Using antimicrobial soap for routine handwashing.

Disinfecting hands immediately after removing gloves.

Keeping gloves on when touching environmental surfaces.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Scabies is a skin infestation caused by the Sarcoptes scabiei mite. While it is contagious, it does not require the use of an N95 respirator mask. Standard precautions, including wearing gloves, are sufficient when caring for a client with scabies.

Choice B rationale:

Mycoplasmal pneumonia is a type of pneumonia caused by the bacteria Mycoplasma pneumoniae. It is typically spread through respiratory droplets and does not require the use of an N95 respirator mask. Standard precautions, including wearing a mask, are appropriate for this condition.

Choice C rationale:

Tuberculosis (TB) is a highly contagious bacterial infection caused by Mycobacterium tuberculosis. TB spreads through the air when an infected person coughs or sneezes. To prevent the inhalation of TB bacteria, healthcare workers should wear N95 respirator masks (or higher level respirators) when caring for clients with active TB disease.

Choice D rationale:

Scarlet fever is a bacterial illness that develops in some people who have strep throat. It is caused by group A Streptococcus bacteria and is typically treated with antibiotics. Scarlet fever does not require the use of an N95 respirator mask. Standard precautions, including wearing gloves and a mask, are appropriate when caring for a client with scarlet fever. Wearing an N95 respirator mask is crucial when caring for clients with airborne infectious diseases like tuberculosis. This type of mask is designed to filter out at least 95% of airborne particles, providing a high level of protection for healthcare workers.

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Correct Answer is A

Explanation

Choice A rationale:

"I will keep my walker at the end of my bed." This statement indicates that the client understands the importance of having the walker within reach. Placing the walker at the end of the bed ensures that the client can use it immediately upon getting up, providing support and stability, thus reducing the risk of falls.

Choice B rationale:

"I will keep the fluorescent ceiling light on in my room at night." While having adequate lighting is important, using a fluorescent ceiling light throughout the night might disrupt the client's sleep. Additionally, a nightlight or a bedside lamp with a low-wattage bulb can provide sufficient illumination without disturbing sleep.

Choice C rationale:

"I will place an area rug at the entry of my bathroom." This statement indicates a lack of understanding. Area rugs can be tripping hazards, especially in areas prone to moisture like bathrooms. It is advisable to remove rugs and ensure non-slip flooring to prevent slips and falls.

Choice D rationale:

"I will place a bath seat in my shower to use when I bathe." While using a bath seat is a good safety measure, it does not address the client's risk of falling outside the shower area. Installing grab bars and non-slip mats in the bathroom, along with removing potential hazards, would be more comprehensive in ensuring the client's safety. .

A. Obtain the blood pressure first thing in the morning. B. Use the appropriate size cuff for the client. C. Make sure the client is relaxed and comfortable prior to obtaining the blood pressure. D. Remove the clothing from arms before obtaining the blood pressure.

Correct Answer is C

Explanation

Choice A rationale:

This option is incorrect. Tachypnea refers to abnormally fast breathing, typically defined as a respiratory rate higher than 20 breaths per minute in adults. It is the opposite of the condition described in the question, where the respiratory rate has fallen below 10 respirations per minute.

Choice B rationale:

This option is incorrect. Apnea refers to the absence of breathing, often resulting from a temporary cessation of airflow to the lungs. It is characterized by the complete absence of respiratory movements and sounds, which is different from the situation described in the question where the client is breathing at a very slow rate.

Choice C rationale:

Bradypnea, or abnormally slow breathing, is the correct answer in this case. It is defined as a respiratory rate lower than the normal range, which is typically between 12 to 20 breaths per minute in adults. Bradypnea can be caused by various factors, including drug overdose, neurological disorders, or metabolic imbalances. In this scenario, the client's slow respiratory rate (below 10 respirations per minute) indicates bradypnea.

Choice D rationale:

This option is incorrect. Eupnea refers to normal breathing, where the rate and depth of respirations are within the normal range. It does not describe the condition of the sedated client in the question, who is experiencing abnormally slow breathing (bradypnea)

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When using standard precautions, the nurse knows that standard precautions mandate what?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who ingested a poison and is now having seizures.Which of the following is the priority action the nurse should take?

Correct Answer is A

Explanation

To accurately take a client's blood pressure, which action by the nurse is most important?

Correct Answer is C

Explanation

To accurately take a client's blood pressure, which action by the nurse is most important?

A nurse is caring for a client who requires contact precautions.Which action should the nurse take with this client?

A nurse is caring for a client when the safety on the bed plug's electrical outlet pops and begins to smoke. Which of the following actions is the nurse's priority?

A nurse is caring for several hospitalized clients.Contact precautions would be mandated for the client with which diagnosis?

A nurse is caring for a group of clients on an infectious disease unit. The nurse should wear an N95 respirator mask when caring for a client who has which of the following disorders?

How often must you or an assistant check on a patient who is restrained?

When the nurse is preparing a sterile field using the drape provided in a sterile pack, the nurse would only touch which part of the sterile drape?

A client has a healthcare-associated infection (HAI) This terminology means what?