A nurse is admitting a client who has pulmonary tuberculosis. Which of the following
transmission-based precautions should the nurse initiate?
Airborne
Rationale: Pulmonary tuberculosis is an infection that is tra
...
A nurse is admitting a client who has pulmonary tuberculosis. Which of the following
transmission-based precautions should the nurse initiate?
Airborne
Rationale: Pulmonary tuberculosis is an infection that is transmitted by airborne
droplets smaller than 5 microns in diameter. Therefore, this client requires
airborne precautions to prevent communicating this infection to others
2. A nurse in a mental health facility is preparing an educational program for a group of
staff nurses about the proper use of restraints. Which of the following information
should the nurse plan to include?
An adult client may be in a mechanical restraint for up to 4 hours
Rational: The nurse should specify that a client who is 18 years or older may be in
a restraint for no more than 4 hr. Children who are 9 to 17 years old are limited
to 2 hr and children who are younger than 9 years old are limited to 1 hr
3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of the following
statements should the nurse make?
Exercise in the morning after arising
Rationale: Daily exercise has many benefits, including enhancing cardiovascular,
psychological, and musculoskeletal health. The nurse should recommend that the
client avoid exercising within 2 hr of bedtime to limit stimulation and enhance
sleep
4. A nurse is preparing to leave the room of a client who is on isolation precautions. Which
of the following actions should the nurse take when removing a tied surgical mask?
Remove the mask by securely holding the ties and moving it away from the face
Rationale: The nurse should untie the bottom strings and then the top strings.
Finally, while still holding the strings, the nurse should remove the mask from her
face. This action prevents the nurse from touching the front of the mask, which is
contaminated
5. A nurse is caring for an adolescent client who is in critical condition following a motor
vehicle crash in which he was the passenger. The client's parent shouts at the nurse,
asking why her son is dying instead of the driver. Which of the following actions should
the nurse take to provide emotional support to the parent?
Inform the parent that anger is a natural response when dealing with loss
Rationale: The nurse should identify that the parent is in the anger stage of grief.
The nurse should assist the parent to understand that anger is a natural response
to loss and encourage her to talk about her feelings
6. A community health nurse is planning prevention strategies for hypertension among
members of her community. The nurse should identify that which of the following ethnic
groups in the community is at greatest risk of developing hypertension?
African Americans
Rationale: Evidence-based practice indicates that individuals of African-American
ethnicity have the highest prevalence of hypertension. Therefore, the nurse
should identify community members of this ethnicity are at greatest risk of
developing hypertension.
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