Questions and Answers
The care plan for a client includes ambulating for 10 minutes every hour, but the client has been unable
to achieve the full amount of time. What is the next step in the nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation - Correct answer
The nurse is caring for a client who is being treated for pneumonia and develops clostridium difficile
from the antibiotic therapy. The client is placed on contact precautions. What interventions should the
nurse perform? Select all that apply.
A. Don a mask prior to entering the client's room.
B. Double bag all trash and label it as contaminated.
C. Remove personal protective equipment (PPE) after leaving the client's room.
D. Provide a disposable blood pressure cuff, thermometer, and stethoscope.
E. Assign the client to a negative pressure room with a high-efficiency particulate air system. - Correct
answer B-
Rationale:
Trash that comes from the room of a client on contact precautions should be double bagged and labeled
D-
Rational:
Disposable equipment needed to obtain vital signs should be left in clients room; this prevent cross-
contamination between clients
Chapter 20- Promoting Asepsis & preventing infection, Pg 667
A- Rational: Mask are required for droplet and airborne precautions, not contact
, C- Rational: The nurse should remove PPE prior to leaving the client's room, not after.
The nurse is providing discharge teaching for a client prescribed a loop diuretic. What should the nurse
include in the teaching? Select all that apply.
A. Change positions slowly.
B. Stay out of direct sunlight.
C. Report any muscle weakness.
D. Notify the healthcare provider of any rash.
E. Signs and symptoms of high potassium levels. - Correct answer A. Rational- Diuretics have side effects
of hypotension and dizziness; therefore, the nurse should teach the client to change positions slowly
C-
Ch 25
. pg 1003
Which describes an organism that carries a pathogen to a susceptible host?
Reservoir
Fomite
Vector
Portal - Correct answer
The client with a diagnosis of advanced pancreatic cancer reports pain of 9 on a scale of 0 to 10. Which
type of pain would the nurse document in the health record?
Visceral pain
Radiating pain
Cutaneous pain
Deep somatic pain - Correct answer
Which should be included in client teaching to support normal bowel elimination? Select all that apply.