1.A nurse is giving chance-of shift report about a client they admitted earlier that day who has pneumonia. Which of
the following pieces of information is the priority for the nurse to provide?
a)Admitting diagnosis.
b)Breath sounds.
c)Body temperature.
d)Diagnostic results.
Correct answer: B. Breath sounds - When using the airway, breathing, circulation approach to client care, the nurse
should determine that the priority information to provide is the current status of the client's breath sounds.
2.A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system.
Which of the following actions should the nurse take first?
a)Rinse the feeding bag with water between feedings.
b)Tell the client to keep the head of the bed elevated at least 30°.
c)Make sure the enteral formula is at room temperature.
d)Wipe the top of the formula can with alcohol.
Correct answer: B. - The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the
bed elevated at least 30° to prevent reflux of the formula into the esophagus
3.A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
a) Place the client in a room with negative-pressure airflow
b)Wear gloves when assisting the client with oral care.
c)Limit each visitor to 2-hr increments.
d)Wear a surgical mask when providing client care.
e)Use antimicrobial sanitizer for hand hygiene
Correct answer: A, B, E. - Place the client in a room with negative-pressure airflow is correct. The nurse should place the
client in a room with negative-pressure airflow to meet the requirements of airborne precautions. Wear gloves when
assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet
the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis.
The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva,
and the mucous membranes in the mouth. Limit each visitor to 2-hr increments is incorrect. The nurse does not need to
limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should
wear a surgical mask when outside of the room. Wear a surgical mask when providing client care is incorrect. The nurse
should wear an N95 respirator during client care to meet the requirements of airborne precautions. Use antimicrobial
sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring
for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly
soiled.
4.A nurse is performing a Romberg test during a physical assessment of a client. Which of the following techniques
should the nurse use?
a)Touch the face with a cotton ball.
b)Apply a vibrating tuning fork to the client's forehead.
c)Have the client stand with their arms at their sides and their feet together.
d)Perform direct percussion over the area of the kidneys.
Correct answer: C - A Romberg test helps identify alterations in balance. The nurse should have the client stand with
their arms at their sides and their feet together to observe for swaying and a loss of balance.
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