All practice questions

3881 questions

Question 1461Question →

An employee health nurse is preparing to administer a Mantoux tuberculin skin test (TST) to a newly hired healthcare worker as part of an occupational health screening protocol. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of steps for administering a tuberculin skin test is to assess for contraindications, prepare the injection site, administer the intradermal injection, verify wheal formation, and instruct the client on follow-up timing.
The sequence reflects the standard nursing process and evidence-based guidelines for administering an intradermal screening test. First, the nurse must perform a targeted assessment to rule out contraindications, such as a history of a positive Mantoux test, which could lead to a severe localized reaction. Once cleared, the nurse prepares the site on the volar forearm using aseptic technique. The administration of the tuberculin solution follows, utilizing a precise 5- to 15-degree angle with the bevel up to ensure intradermal placement. Immediately following the injection, the nurse evaluates the site for the formation of a 6 to 10 mm wheal, which confirms correct technique. Finally, the nurse provides client education regarding the strict 48- to 72-hour timeframe required for an accurate reading of the screening results.

Step-by-Step Solution

1
Assess the client's history for previous positive reactions or severe reactions to the tuberculin skin test.
The nurse confirms the client is a safe candidate for the screening.
Administering a TST to someone with a prior positive result can cause severe hypersensitivity reactions, including tissue necrosis.
2
Cleanse the volar surface of the forearm with an alcohol swab and allow it to dry completely.
The injection site is properly prepared and sanitized.
Cleansing the skin reduces the risk of introducing surface flora into the dermis during the injection.
3
Insert the needle at a 5- to 15-degree angle with the bevel pointing upward and inject the tuberculin solution.
The purified protein derivative (PPD) is deposited into the intradermal space.
The correct angle and bevel position are necessary to ensure the medication stays within the dermal layer rather than going subcutaneously.
4
Confirm the appearance of a 6 to 10 mm pale wheal at the injection site immediately after administration.
The correct intradermal placement of the screening agent is visually verified.
If no wheal forms, or if it is too small, the injection may have been too deep, invalidating the screening test and requiring a repeat injection.
5
Educate the client to return to the healthcare facility in 48 to 72 hours for the screening interpretation.
The client understands the required timeframe for test evaluation.
A TST must be read by a trained professional within the 48- to 72-hour window; otherwise, the screening is invalid and must be repeated.

Key Concept

Tuberculosis Screening and Intradermal Injection Protocol
Question 1462Question →

A critical care nurse is managing a 72-year-old client with septic shock who is mechanically ventilated and receiving continuous vasopressor infusions. As sedation is lightened, the client exhibits acute delirium, becomes highly agitated, and repeatedly grasps at their endotracheal tube. The healthcare provider prescribes bilateral soft wrist restraints to prevent self-extubation. Which of the following nursing plans demonstrates the most accurate synthesis of safety guidelines, delegation, and restraint protocols?

Show answer & explanation

Answer: Secure the restraints to the movable portion of the bed frame using quick-release ties, assign the unlicensed assistive personnel (UAP) to provide routine skin care, and perform an RN evaluation of peripheral perfusion at least every two hours.

Answer

The nurse must secure the restraints to the movable portion of the bed frame using quick-release ties, delegate routine non-clinical tasks to the UAP, and perform the neurovascular assessments at least every two hours.
The correct plan represents the standard of care for non-violent (medical-surgical) restraints used to support medical healing. The nurse correctly secures the restraints to the movable portion of the bed frame using quick-release knots to prevent injury if the bed position changes. Furthermore, the nurse appropriately delegates routine, non-assessorial tasks like skin care to the UAP, while retaining the responsibility for clinical assessments (such as peripheral perfusion and the ongoing need for restraints), which must be conducted at least every two hours.

Step-by-Step Solution

1
Analyze the clinical indication and prioritize interventions.
The client is at immediate risk of self-extubation (Airway).
Airway protection takes absolute priority over hemodynamic titration in this critical moment, necessitating immediate safe application of the ordered restraints.
2
Determine safe restraint application techniques.
Restraints must be secured with quick-release knots to the movable portion of the bed frame.
Securing restraints to the movable frame prevents injury when bed positioning changes, and quick-release knots ensure rapid removal during emergencies.
3
Evaluate delegation boundaries.
Routine skin care is delegated to the UAP; clinical assessments are retained by the RN.
UAPs cannot perform clinical judgments such as airway patency monitoring or neurovascular assessments.
4
Verify legal compliance for restraint orders.
Ensure the order is time-limited and not PRN.
CMS regulations strictly prohibit PRN (as-needed) orders for both physical and chemical restraints.

Key Concept

Management of Medical-Surgical Restraints and Prioritization
Question 1463Question →

A 32-year-old client admitted to the inpatient behavioral health unit with acute mania becomes severely agitated and physically strikes a staff member. After verbal de-escalation and pharmacological interventions fail to calm the client, the emergency response team applies four-point mechanical restraints. Which nursing action demonstrates strict compliance with safety and regulatory standards for violent restraint use?

Show answer & explanation

Answer: Ensuring the healthcare provider completes an in-person clinical evaluation of the client within 1 hour of the restraint application.

Answer

Ensuring the healthcare provider completes an in-person clinical evaluation of the client within 1 hour of the restraint application.
For a client placed in violent or behavioral mechanical restraints, federal guidelines (such as those by CMS) and accreditation bodies (like The Joint Commission) mandate that a healthcare provider, advanced practice nurse, or physician assistant must conduct a face-to-face clinical evaluation within 1 hour of the application. This rapid evaluation ensures that the client's physical and psychological status is safe, and confirms that this extreme measure is legally and medically justified.

Step-by-Step Solution

1
Identify the classification of the restraint being applied.
The restraints applied to manage physical aggression and violence are classified as violent or behavioral restraints.
Regulatory standards differentiate between non-violent (medical/surgical) and violent (behavioral) restraints, with the latter requiring much stricter monitoring and evaluation protocols.
2
Recall the legal and regulatory mandates specifically for violent restraints.
Centers for Medicare & Medicaid Services (CMS) and The Joint Commission mandate that a healthcare provider must perform a face-to-face assessment within 1 hour of applying violent restraints.
Violent restraints pose an exceptionally high risk of physical injury, psychological trauma, or death, necessitating immediate medical evaluation to confirm the necessity and ensure client safety.
3
Evaluate the incorrect actions to identify violations of safety, delegation, or prioritization.
Delegating neurovascular assessments to a UAP, requesting PRN restraint orders, and prioritizing documentation over direct client observation all violate core nursing standards.
The RN cannot delegate clinical assessments, PRN restraint orders are strictly forbidden by law, and the physical safety of a restrained client must always supersede administrative tasks like incident reporting.

Key Concept

Violent and Behavioral Restraint Regulatory Standards
Question 1464Question →

A pediatric nurse is evaluating the cognitive development of various clients across the lifespan according to Piaget's theory of cognitive development. Arrange the following clinical observations in the chronological order of their expected developmental emergence, from earliest to latest.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence of cognitive development is: 1) Neonatal rooting reflex (early sensorimotor), 2) Searching for a hidden object (object permanence, late sensorimotor), 3) Believing an inanimate pump is angry (animism, preoperational), 4) Understanding volume does not change when transferred (conservation, concrete operational), and 5) Formulating a hypothesis (abstract reasoning, formal operational).
Cognitive development progresses sequentially through Piaget's stages: sensorimotor (innate reflexes, followed by object permanence), preoperational (animism and magical thinking), concrete operational (conservation of volume and mass), and formal operational (abstract hypothesis testing).

Step-by-Step Solution

1
Analyze the observation of a neonate turning their head when their cheek is stroked.
This is the rooting reflex, an innate behavior present from birth during the earliest phase of the sensorimotor stage (0 to 1 month).
Identifying the earliest developmental baseline is necessary to start the sequence.
2
Analyze the observation of an infant searching for a completely covered stethoscope.
This demonstrates object permanence, which develops during the later part of the sensorimotor stage (approximately 8 to 12 months).
Differentiating innate reflexes from learned cognitive concepts within the sensorimotor stage establishes the first two chronological steps.
3
Evaluate the child stating the infusion pump is 'angry' and will bite.
This illustrates animism, a characteristic of the preoperational stage, typically seen in toddlers and preschoolers (ages 2 to 7 years).
Preoperational magical thinking developmentally follows the sensorimotor stage.
4
Assess the school-age client recognizing that transferring liquid does not change its volume.
This indicates mastery of conservation, a hallmark of the concrete operational stage (ages 7 to 11 years).
Concrete logical reasoning regarding physical properties develops after preoperational thought.
5
Examine the adolescent formulating a hypothesis about insulin times and blood glucose.
This reflects hypothetico-deductive reasoning, defining the formal operational stage (ages 11 and older).
Abstract and hypothesis-driven thought is the final stage of Piaget's cognitive development.

Key Concept

Piaget's Theory of Cognitive Development (Sensorimotor, Preoperational, Concrete Operational, Formal Operational)
Question 1465Question →

A nurse is implementing care for a client who currently requires physical wrist restraints to prevent interference with a newly inserted percutaneous endoscopic gastrostomy (PEG) tube. Which of the following interventions must the nurse include in the client's plan of care? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Attach the restraint straps to the movable portion of the bed frame.; Remove the restraints at least every 2 hours to provide skin care and range-of-motion exercises.; Document the specific client behaviors that indicate the continued need for the restraints.

Answer

The correct interventions are attaching the straps to the movable portion of the bed frame, removing the restraints at least every 2 hours for care, and documenting specific behaviors indicating the continued need for restraints.
Safe restraint use mandates attaching straps to the movable part of the bed frame to prevent traction injury during bed adjustments, removing them at least every 2 hours to ensure circulation and joint mobility, and maintaining strict documentation of the behaviors justifying their ongoing use.

Step-by-Step Solution

1
Identify the core subject of the scenario.
The scenario requires selecting safe, legally compliant, and standard nursing interventions for a client with physical restraints.
Recognizing the guidelines for restraint use dictates the correct actions and prevents patient harm.
2
Evaluate each option based on established safety protocols.
Attaching to a movable frame, providing care every 2 hours, and documenting specific behaviors are standard safe practices.
These actions protect the client from mechanical injury, physiological compromise, and ensure legal justification for the restraints.
3
Identify contraindicated actions and unsafe practices in the remaining options.
Tying restraints to side rails, using square knots, relying on PRN orders, and delegating assessment to UAP are identified as dangerous or legally impermissible.
Side rails move independently and can cause severe injury; square knots delay emergency removal; PRN orders are legally banned; and assessments require registered nurse judgment.

Key Concept

Standard safety protocols, legal guidelines, and proper delegation regarding the use of physical restraints.
Question 1466Question →

A client presents to the emergency department walk-in entrance following an industrial accident. The client's clothing and exposed skin are heavily covered in an unidentified dry, powdery chemical. The client is highly distressed and reports intense burning on their arms and chest. Which action should the triage nurse take first?

Show answer & explanation

Answer: Don appropriate personal protective equipment, keep the client outside the facility, and carefully brush the powder off the skin.

Answer

The priority action is to don appropriate personal protective equipment, keep the client outside the facility to prevent contamination of the emergency department, and carefully brush the dry chemical powder off the skin and clothing.
When a client is exposed to an unidentified dry chemical powder, the immediate priorities are to prevent further injury to the client and to protect the healthcare facility and personnel from secondary contamination. A contaminated client must remain outside the facility until properly decontaminated. Furthermore, dry chemicals must be carefully brushed off the skin and clothing before any water is applied. Adding water to an unknown dry chemical can cause a severe exothermic (heat-releasing) reaction, which can result in extensive thermal burns.

Step-by-Step Solution

1
Analyze the hazardous material presentation.
The client is covered in an unidentified dry chemical powder.
Identifying the physical state of the chemical (dry versus liquid) dictates the safest initial decontamination strategy.
2
Evaluate the risk to the facility and other personnel.
The client is currently outside the emergency department.
A contaminated client must not enter the facility until decontaminated. Allowing them inside would expose the entire environment, staff, and other vulnerable clients to the hazardous material.
3
Determine the safest decontamination method for a dry chemical.
Dry chemicals must be brushed off the skin and clothing before applying any liquids.
Applying water to an unknown dry chemical can trigger a violent exothermic (heat-releasing) reaction, resulting in severe thermal burns that compound the chemical injury.
4
Select the priority nursing action based on safety protocols.
The nurse must don personal protective equipment, keep the client outside, and brush off the dry powder.
This action protects the rescuer, secures the facility, and utilizes the correct decontamination technique for a dry hazard.

Key Concept

Hazardous Materials (HazMat) Decontamination Protocols
Question 1467Question →

A pediatric nurse is conducting a 24-month well-child visit and developmental screening. The parents express anxiety, stating, 'Our child is not sharing toys with other children at daycare and only speaks in two-word phrases, never three-word sentences.' As the nurse approaches the examination table, the toddler clings to the parent and begins to cry. Which sequence of nursing actions represents the most appropriate approach to this screening assessment?

Show answer & explanation

Answer: Reassure the parents that parallel play and two-word phrases are normal milestones for this age, and begin the physical screening by auscultating the heart and lungs while the child sits on the parent's lap.

Answer

The most appropriate action is to reassure the parents that parallel play and two-word phrases are normal for a 24-month-old, and to begin the physical screening by auscultating the heart and lungs while the child sits on the parent's lap.
The correct sequence prioritizes developmentally appropriate reassurance and modifies the physical examination to accommodate the toddler's psychosocial needs. At 24 months, children typically speak in two-word phrases and engage in parallel play rather than cooperative sharing. Recognizing these as normal milestones prevents inappropriate labeling of a delay. Furthermore, auscultating the heart and lungs while the child is quiet and secure on the parent's lap represents the standard pediatric assessment principle of moving from least invasive to most invasive.

Step-by-Step Solution

1
Evaluate the developmental milestones reported by the parents for a 24-month-old child.
At 24 months, using two-word phrases (with a vocabulary of 50+ words) and engaging in parallel play (playing alongside others without sharing) are expected, normal findings.
Accurate knowledge of developmental stages prevents unnecessary referrals, reduces parental anxiety, and guides the correct focus of the screening.
2
Determine the most effective physical assessment sequence for a distressed toddler.
The assessment should proceed opportunistically from least invasive to most invasive while allowing the child to remain in a secure position (the parent's lap).
Toddlers experience significant stranger anxiety and fear of invasive procedures; forcing them onto an exam table increases distress and hinders accurate assessment of vital signs and breath sounds.
3
Differentiate between primary and secondary prevention strategies in the context of the visit sequencing.
Immunizations (primary prevention) cause pain and should be deferred until the very end of the visit, after the developmental and physical screening (secondary prevention) is complete.
Administering injections early will cause prolonged crying, making the rest of the physical screening impossible to perform accurately.

Key Concept

Pediatric Developmental Screening and Assessment Modifications
Estimated Time:2m 0s
Question 1468Question →

A newly admitted client who is receiving immunosuppressive therapy for a renal transplant develops fluid-filled blisters across multiple dermatomes on the chest, back, and face. The healthcare provider suspects disseminated herpes zoster. Which infection control protocols should the nurse initiate for this client? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Assign the client to a private isolation room with negative air pressure.; Don a fit-tested N95 respirator, disposable gown, and clean gloves before entering the client's room.; Dedicate reusable medical equipment, such as a stethoscope and blood pressure cuff, exclusively for this client's use.

Answer

The correct interventions are assigning the client to a negative-pressure isolation room, donning an N95 respirator with a gown and gloves, and dedicating reusable equipment exclusively to the client.
Disseminated herpes zoster in an immunocompromised client requires both Airborne and Contact precautions until all lesions have crusted over. This mandates a negative-pressure isolation room, an N95 respirator, a gown, gloves, and dedicated medical equipment to prevent the spread of the varicella-zoster virus.

Step-by-Step Solution

1
Analyze the clinical presentation.
The client is immunosuppressed and has widespread vesicular lesions across multiple dermatomes, indicating disseminated herpes zoster.
Identifying the specific condition and client immune status is required to determine the necessary transmission-based precautions.
2
Determine the appropriate isolation categories.
Disseminated herpes zoster in an immunocompromised client necessitates both Airborne and Contact precautions.
While localized shingles in an immunocompetent adult may only require Standard or Contact precautions, the disseminated form spreads via airborne particles and direct contact with fluid from uncrusted lesions.
3
Select interventions that comply with Airborne precautions.
The nurse must use a negative-pressure room and wear an N95 respirator. The N95 must be removed outside the room. If transport is needed, the client wears a standard surgical mask.
These measures prevent the inhalation and spread of suspended infectious droplet nuclei.
4
Select interventions that comply with Contact precautions.
The nurse must wear a gown and gloves during care and dedicate reusable medical equipment to the client's room.
These measures prevent the spread of the pathogen via direct contact with the client or their contaminated environment.
5
Evaluate delegation safety.
Wound care and topical medication administration for open lesions cannot be delegated to a UAP.
Applying medicated ointments to active infectious lesions involves nursing assessment and falls outside the UAP scope of practice.

Key Concept

Transmission-Based Precautions for Disseminated Herpes Zoster
Question 1469Question →

During a community wellness fair, a nursing team is providing various services across the lifespan. The team leader is evaluating the different stations to ensure a proper balance of health promotion levels. Which of the following activities correctly represent secondary prevention (health screening)? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Performing vision and hearing evaluations for preschool-aged children.; Conducting blood glucose testing for adults who are overweight.; Performing routine cervical cancer screening via Papanicolaou (Pap) testing for adult females.

Answer

The activities that represent secondary prevention are performing vision and hearing evaluations, conducting blood glucose testing, and performing cervical cancer screening.
Secondary prevention focuses on the early detection and prompt treatment of health issues before they become symptomatic or advanced. Routine health screenings, such as vision and hearing evaluations, blood glucose testing, and Papanicolaou (Pap) testing, are prime examples of secondary prevention. They do not stop the initial pathology from starting, but they detect it early enough to improve outcomes.

Step-by-Step Solution

1
Define the concept of secondary prevention in the context of health promotion.
Secondary prevention focuses on early detection (screening) and prompt intervention for asymptomatic diseases to halt or slow progression.
Understanding the precise definition is required to differentiate screening from other levels of prevention.
2
Evaluate each provided option to determine its prevention level (primary, secondary, or tertiary).
Evaluations, blood tests, and Pap smears are early detection screenings (secondary). Immunizations and education are aimed at avoiding disease entirely (primary). Rehabilitation and mobility training manage an existing condition (tertiary).
This accurately categorizes each clinical activity into the correct level of health promotion.

Key Concept

Secondary Prevention and Health Screening
Question 1470Question →

A nurse is admitting an 81-year-old client who presents to the emergency department with diffuse abdominal pain, nausea, and recent episodes of sudden confusion. An unlicensed assistive personnel is available to assist with the admission process. Which action by the nurse demonstrates the appropriate approach to this client's physical assessment?

Show answer & explanation

Answer: Auscultating all four abdominal quadrants for bowel sounds before proceeding to percussion and palpation.

Answer

The correct action is auscultating all four abdominal quadrants for bowel sounds before proceeding to percussion and palpation.
When performing a physical assessment of the abdomen, the standard sequence of techniques is purposefully altered. The correct order is inspection, auscultation, percussion, and palpation. Auscultating before palpation and percussion is essential because manual manipulation can stimulate peristalsis, thereby artificially altering the character and frequency of bowel sounds.

Step-by-Step Solution

1
Analyze the required sequence for an abdominal physical assessment.
The standard sequence (inspection, palpation, percussion, auscultation) must be altered for the abdomen to inspection, auscultation, percussion, palpation.
This prevents manual manipulation of the abdomen from artificially altering the frequency or character of bowel sounds.
2
Evaluate the delegation appropriateness for physical assessment tasks.
Initial physical assessments, particularly those requiring clinical judgment like auscultation, must be performed by the registered nurse.
Unlicensed assistive personnel do not have the scope of practice or training to perform initial assessments or interpret clinical findings.
3
Assess the clinical significance of sudden confusion in an older adult.
Sudden confusion is recognized as a red flag for acute illness, not a normal part of aging.
Older adults often present atypically to systemic stress, and sudden cognitive changes mandate thorough investigation for underlying physiological causes.

Key Concept

Abdominal Assessment Sequence and Geriatric Considerations
Question 1471Question →

A 7-year-old client is admitted to the pediatric unit for a prolonged course of intravenous antibiotics to treat osteomyelitis. To promote normal psychosocial development based on Erikson's stages, which intervention should the nurse prioritize?

Show answer & explanation

Answer: Provide the client with structured craft projects and coordinate with teachers to continue schoolwork.

Answer

Provide the client with structured craft projects and coordinate with teachers to continue schoolwork.
According to Erikson's theory of psychosocial development, a 7-year-old is in the 'Industry versus Inferiority' stage. Children in this stage thrive on learning, completing tasks, and gaining a sense of competence. Providing schoolwork and structured projects allows the hospitalized child to remain productive and achieve goals, thereby promoting industry and preventing feelings of inferiority.

Step-by-Step Solution

1
Identify the client's age and corresponding developmental stage according to Erikson's theory.
The client is 7 years old, placing them in the school-age stage (6 to 12 years), which is characterized by the psychosocial crisis of Industry versus Inferiority.
Nursing interventions must be tailored to the client's specific cognitive and psychosocial developmental level to be effective and safe.
2
Determine the primary psychosocial needs of a child in the Industry versus Inferiority stage.
Children at this stage need to engage in tasks they can complete, learn new skills, and feel a sense of accomplishment and competence.
Prolonged hospitalization can disrupt normal development; providing opportunities for achievement prevents feelings of inadequacy or inferiority.
3
Evaluate the given options to find the one that best supports the development of industry.
Providing craft projects and schoolwork allows the child to continue learning, complete tasks, and feel productive, which perfectly aligns with fostering industry.
The other options incorrectly target the developmental needs of preschoolers, adolescents, or promote regressive dependence.

Key Concept

Erikson's Psychosocial Stages: Industry vs. Inferiority (School-Age)
Estimated Time:1m 0s
Question 1472Question →

A glass vacutainer tube containing a client's blood has accidentally dropped and shattered on the floor of the clinical unit. The nurse has retrieved the biological spill kit. Arrange the following actions in the correct sequence to safely manage this hazardous materials spill.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: 1) Don appropriate PPE, 2) Use tongs to retrieve the glass fragments, 3) Deposit the glass into a sharps container, 4) Place absorbent pads over the blood spill, 5) Apply a 1:10 sodium hypochlorite solution to the surface.
When managing a biohazardous spill involving broken glass, the nurse must prioritize personal safety by first donning appropriate personal protective equipment (PPE). The immediate physical hazard (broken glass) must be removed next using mechanical means, such as tongs, to prevent percutaneous injury. These sharps must be immediately secured in a puncture-resistant container. Once the sharps are safely removed, the organic material (blood) should be absorbed with pads or towels to prevent it from inactivating the cleaning agent. Finally, an appropriate chemical disinfectant, such as a 1:10 sodium hypochlorite (bleach) solution, is applied to the surface to destroy any remaining bloodborne pathogens.

Step-by-Step Solution

1
Put on personal protective equipment (PPE).
The nurse is protected from bloodborne pathogens and potential physical injury.
Safety of the healthcare worker is the first priority before handling any hazardous material.
2
Pick up the broken glass with tongs or forceps.
The physical sharps hazard is safely removed from the spill without risking a percutaneous injury.
Glass fragments can puncture standard gloves; mechanical removal prevents direct contact with the sharps.
3
Discard the glass into a sharps container.
The broken glass is securely contained.
Puncture-resistant containers prevent subsequent injuries to environmental services or other staff members.
4
Absorb the remaining blood with paper towels or absorbent pads.
The bulk of the biohazardous fluid is removed from the surface.
Chemical disinfectants are inactivated by large amounts of organic material; the spill must be absorbed before chemical disinfection.
5
Apply a bleach solution (1:10) to the area.
The surface is chemically decontaminated.
Appropriate contact time with a tuberculocidal or bleach solution destroys remaining bloodborne pathogens.

Key Concept

Standard precautions and OSHA guidelines for biological spills involving sharps require immediate mechanical removal of the sharps hazard, followed by absorption of organic material, and concluding with chemical decontamination.
Estimated Time:2m 0s
Question 1473Question →

A nurse is preparing to send a sputum specimen to the laboratory for a client with suspected active pulmonary tuberculosis (TB). Which action demonstrates the appropriate handling and transport of this highly infectious material?

Show answer & explanation

Answer: Placing the tightly closed specimen container into a sealable biohazard transport bag and hand-delivering it to the laboratory.

Answer

The specimen must be secured inside a secondary biohazard transport bag and manually delivered to the laboratory.
The correct action involves placing the primary specimen container into a secondary leak-proof biohazard bag and hand-delivering it to the laboratory. Tuberculosis is a virulent airborne pathogen, and a secondary bag is legally and clinically required to prevent exposure in case the primary cup leaks or is dropped. Hand-delivery is mandatory because sending highly infectious respiratory specimens through a pneumatic tube system creates a severe risk of widespread aerosolization if the container were to break open inside the pressurized tubes.

Step-by-Step Solution

1
Verify the primary specimen container is tightly closed.
Prevents immediate leakage of the highly infectious sputum out of the primary cup.
Tuberculosis is transmitted via airborne droplets, making proper source containment the first critical step.
2
Place the primary container into a secondary, leak-proof biohazard transport bag.
Provides an additional layer of protection against spills or surface contamination during transit.
OSHA and CDC guidelines mandate secondary containment for all biohazardous laboratory specimens to protect healthcare workers and the environment.
3
Hand-deliver the bagged specimen to the laboratory without wearing isolation PPE in the hallways.
Ensures safe arrival without risking system-wide contamination or violating public space infection control boundaries.
Pneumatic tube systems can break the container, potentially aerosolizing TB bacteria throughout the hospital's ventilation and tube network.

Key Concept

Handling and Transporting Highly Infectious Biological Specimens
Question 1474Question →

A nurse in an ambulatory care clinic is reviewing health promotion and disease prevention strategies with a group of nursing students. Which scenario identified by a student demonstrates an accurate understanding and application of secondary prevention?

Show answer & explanation

Answer: Scheduling a 65-year-old asymptomatic female client for a routine dual-energy x-ray absorptiometry (DEXA) scan

Answer

Scheduling a 65-year-old asymptomatic female client for a routine dual-energy x-ray absorptiometry (DEXA) scan.
The correct answer accurately identifies a secondary prevention strategy, which focuses on the early detection and treatment of disease in asymptomatic individuals. Scheduling an asymptomatic 65-year-old woman for a screening DEXA scan perfectly exemplifies this level of prevention, as it aims to detect osteoporosis early before fractures occur.

Step-by-Step Solution

1
Define secondary prevention in the context of health promotion.
Secondary prevention involves early detection, screening, and prompt treatment of diseases in asymptomatic individuals to halt disease progression.
Establishing the definition helps accurately categorize the clinical interventions.
2
Analyze each option against the definition of secondary prevention.
Vaccinations are primary prevention. Post-stroke physical therapy is tertiary prevention. A screening DEXA scan is secondary prevention.
Differentiating the levels of prevention isolates the correct category.
3
Evaluate the clinical appropriateness of the remaining screening interventions.
A routine DEXA scan for a 65-year-old woman aligns with evidence-based guidelines. Using a Snellen chart for a 15-month-old is developmentally incorrect.
An option must be both clinically accurate and categorized correctly to demonstrate accurate student understanding.

Key Concept

Levels of Disease Prevention and Appropriate Screening Modalities
Question 1475Question →

An older adult client is admitted to an acute care facility with severe, acute gastroenteritis. Laboratory testing confirms a norovirus infection. Which of the following infection control interventions should the registered nurse include in the client's plan of care? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Assign the client to a single-occupancy room with a dedicated bathroom.; Perform hand hygiene strictly using soap and water upon exiting the room.; Don a clean gown and non-sterile gloves immediately prior to room entry.

Answer

Assign the client to a single-occupancy room with a dedicated bathroom, perform hand hygiene strictly using soap and water upon exiting the room, and don a clean gown and non-sterile gloves immediately prior to room entry.
Norovirus requires contact and enteric precautions. To prevent the spread of this highly contagious virus, the client must be isolated in a private room with a dedicated bathroom. Healthcare workers must wear a gown and gloves upon entering to prevent uniform and hand contamination. Because norovirus is resistant to alcohol-based hand sanitizers, hand hygiene must be performed strictly using soap and water to mechanically wash away the viral particles.

Step-by-Step Solution

1
Identify the infectious agent and its primary mode of transmission.
Norovirus is highly contagious and transmits primarily through the fecal-oral route and direct contact with contaminated surfaces.
Understanding the mode of transmission is the foundation for determining the appropriate tier of isolation precautions.
2
Determine the necessary isolation precaution category.
The client requires Contact Precautions, specifically enteric precautions due to the nature of the pathogen.
Standard and Contact Precautions dictate the use of barriers and specific room assignments to halt transmission.
3
Select interventions that align with enteric contact precautions.
Appropriate interventions include a private room, donning gown and gloves upon entry, and utilizing soap and water for hand hygiene instead of alcohol-based rubs.
Alcohol-based sanitizers lack efficacy against certain enteric pathogens like norovirus and Clostridioides difficile, making mechanical removal with soap and water essential.

Key Concept

Contact and Enteric Precautions for Gastroenteritis
Question 1476Question →

During a clinical rotation, a nursing student is assigned to change the bed of a client following a large incontinent episode. The registered nurse preceptor observes the student handling the heavily soiled bed linens. Which of the following actions by the student demonstrate correct infection control principles for handling infectious materials? (Select all that apply)

Select all that apply

Show answer & explanation

Answer: Folding the contaminated surface of the linen inward before rolling it; Carrying the bundle of soiled linens away from the body to prevent uniform contamination; Placing the gathered linens into a designated leak-proof laundry bag immediately at the bedside

Answer

The correct actions are folding the contaminated surface inward, carrying the linens away from the body, and placing them directly into a leak-proof laundry bag at the bedside.
The correct actions demonstrate strict adherence to standard infection control protocols. Folding the soiled areas inward contains the organic material and pathogens. Carrying linens away from the uniform prevents cross-contamination to the healthcare worker's clothing. Placing the linens directly into a designated leak-proof bag at the point of use minimizes environmental exposure and the risk of transmitting microorganisms to other areas.

Step-by-Step Solution

1
Identify the primary goal of handling infectious or soiled materials.
The objective is to contain pathogens, protect the healthcare worker, and prevent environmental contamination.
Standard precautions mandate that all organic material must be treated as potentially infectious and handled with care to prevent spread.
2
Evaluate each provided action against standard infection control guidelines for soiled linen.
Folding inward, holding away from the body, and direct disposal at the point of use align with containment principles. Shaking or placing linens on the floor violates these principles.
Pathogens can easily be aerosolized or transferred to surfaces and clothing if not handled with minimal agitation and immediate containment.

Key Concept

Safe Handling of Infectious and Soiled Linens
Question 1477Question →

A primary care nurse is reviewing the health records of four clients to determine their need for annual lung cancer screening with low-dose computed tomography (LDCT). Based on current evidence-based screening guidelines, which client should the nurse identify as meeting the criteria for this screening?

Show answer & explanation

Answer: A 68-year-old client who has a 30 pack-year smoking history and quit smoking 10 years ago

Answer

The 68-year-old client who has a 30 pack-year smoking history and quit smoking 10 years ago is the correct candidate for LDCT screening.
The correct answer identifies the client who meets all three criteria established by current preventive health guidelines for annual low-dose computed tomography (LDCT) lung cancer screening. To qualify, a client must be between 50 and 80 years old, possess a smoking history of 20 pack-years or greater, and either currently smoke or have quit within the past 15 years. The 68-year-old client with a 30 pack-year history who quit 10 years ago perfectly matches this risk profile.

Step-by-Step Solution

1
Identify the current age criteria for LDCT lung cancer screening.
The client must be between 50 and 80 years of age.
Screening outside this age range lacks evidence of a mortality benefit that outweighs the risks of false positives and unnecessary invasive procedures.
2
Determine the required smoking history threshold.
The client must have a smoking history of at least 20 pack-years.
This threshold specifically identifies individuals at a high enough statistical risk for lung cancer to benefit from secondary prevention measures.
3
Evaluate the smoking status and quit-time limits.
The client must be a current smoker or have quit within the past 15 years.
After 15 years of smoking cessation, the risk of lung cancer drops significantly, and the risks of routine LDCT screening begin to outweigh the benefits.
4
Analyze each client profile against all three established criteria.
Only the 68-year-old client meets the age, pack-year, and timeframe-since-quitting requirements.
Accurate application of screening guidelines requires satisfying every component of the inclusion criteria.

Key Concept

Secondary prevention criteria require precise application of multiple demographic and historical variables (age, pack-years, years since quitting) to correctly identify candidates for annual LDCT lung cancer screening.
Question 1478Question →

A clinic nurse is reviewing the electronic health records of four female clients scheduled for routine annual visits. According to standard preventive health guidelines, which client should the nurse identify as requiring an initial dual-energy x-ray absorptiometry (DEXA) scan for osteoporosis screening?

Show answer & explanation

Answer: An asymptomatic 65-year-old client with no significant past medical history

Answer

An asymptomatic 65-year-old client with no significant past medical history
Current national health guidelines and consensus recommendations state that all women aged 65 years and older should undergo routine bone mineral density screening for osteoporosis using a DEXA scan. This is a standard secondary prevention measure for this age group, regardless of whether they have a significant medical history or are completely asymptomatic.

Step-by-Step Solution

1
Analyze the stem to determine the specific health screening being asked about.
The question asks for the appropriate client to receive an initial DEXA scan for osteoporosis screening.
Identifying the target screening protocol dictates which clinical guidelines apply.
2
Recall the standard evidence-based guidelines for osteoporosis screening in women.
Routine screening is recommended for all women aged 65 and older.
Applying knowledge of health promotion and maintenance guidelines is necessary to select the correct client.
3
Evaluate each client option against the screening criteria.
Only the 65-year-old client meets the age threshold for routine screening.
The other clients are either too young, presenting with unrelated joint symptoms, or engaging in primary prevention without an indication for early secondary screening.

Key Concept

Osteoporosis Screening Guidelines
Estimated Time:45s
Question 1479Question →

A registered nurse in a neurorehabilitation unit is caring for a client with a traumatic brain injury who is exhibiting severe psychomotor agitation and is repeatedly attempting to dislodge their percutaneous endoscopic gastrostomy (PEG) tube. Arrange the following nursing actions in the correct chronological sequence, prioritizing from the least restrictive interventions to the most restrictive, while adhering to evidence-based restraint protocols. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct clinical sequence begins with assessing for reversible physiological causes of agitation, followed by non-contact environmental de-escalation. If agitation persists, the nurse should conceal the medical device. When all alternatives fail, bilateral soft wrist restraints are applied and immediately anchored to the articulating bed frame using quick-release knots. Finally, ongoing care requires sequentially releasing the restraints every two hours for neurovascular assessment.
The established nursing standard of care demands a progressive approach to client agitation, starting with the least restrictive measures. The nurse must first assess for and correct any underlying physiological causes (e.g., hypoxia). If the behavior continues, non-contact interventions (environmental de-escalation) are utilized, followed by contact alternatives (concealing the device with a binder). Only when these measures fail to protect the client's medical treatment are physical restraints applied. Once applied, the immediate priority is safely securing them to the movable bed frame with quick-release knots, followed by initiating the regulatory requirement of releasing them every two hours for comprehensive neurovascular assessments.

Step-by-Step Solution

1
Evaluate for reversible physiological determinants of agitation.
Rules out hypoxia, pain, or a full bladder as the primary physiological catalyst.
Clinical assessment is the mandatory first step of the nursing process prior to implementing any intervention.
2
Institute environmental de-escalation strategies.
Modifies the client's sensory input and environment.
Environmental modification is the least restrictive, non-contact intervention to manage behavioral agitation.
3
Conceal the PEG tube beneath an abdominal binder.
Blocks visual and tactile access to the medical device.
This acts as a targeted physical barrier and is a less restrictive alternative to restraining the client's upper extremities.
4
Apply bilateral soft wrist restraints.
Prevents the client's hands from grasping the abdomen.
Physical restraints are utilized strictly as a last resort when less restrictive measures fail to protect life-sustaining medical treatments.
5
Anchor restraint straps to the articulating bed frame with quick-release knots.
Secures the physical restraints safely.
Tying to the movable frame prevents traction injuries when the bed's position is adjusted, and quick-release ties ensure rapid removal during emergencies.
6
Release restraints sequentially every two hours for neurovascular assessment.
Maintains skin integrity and peripheral tissue perfusion.
This is the mandated regulatory standard of care for clients placed in non-violent medical-surgical restraints.

Key Concept

Hierarchy of restrictive interventions and safe application of physical restraints
Question 1480Question →

A client arrives at a community clinic triage desk exhibiting a high fever, cough, coryza, and a diffuse maculopapular rash. The triage nurse suspects rubeola (measles). Arrange the following nursing interventions in the correct chronological sequence to effectively implement transmission-based precautions.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first apply a surgical mask to the client for source control, escort them to an airborne infection isolation room, secure the door to establish negative pressure, don an N95 respirator for self-protection, and finally proceed with the clinical assessment.
For highly contagious airborne pathogens like rubeola (measles), immediate containment is the primary goal. Source control (masking the client) is the fastest, most effective first action. Moving the client to a negative-pressure room and sealing the door establishes environmental control. Finally, ensuring the nurse is protected with an N95 respirator allows for safe, sustained close contact during the physical assessment.

Step-by-Step Solution

1
Initiate source control
The client wears a surgical mask over their nose and mouth.
Placing a mask on the infectious client immediately stops the wide dispersion of airborne viral particles into the public waiting area.
2
Relocate to an appropriate isolation environment
The client is moved from the triage desk to an AIIR.
Airborne pathogens require negative-pressure ventilation systems to safely exhaust contaminated air outside the facility.
3
Secure the isolation environment
The AIIR door is completely closed.
Negative pressure cannot be maintained if the door is open, which would allow infectious air to circulate into adjoining corridors.
4
Apply staff personal protective equipment
The nurse dons an N95 respirator.
Healthcare personnel must have high-level filtration protection (N95 or PAPR) before inhaling the ambient air inside an airborne isolation room.
5
Conduct nursing care
The comprehensive clinical assessment is performed.
Safe patient care can only be provided once transmission risks to the public, facility, and healthcare worker are neutralized.

Key Concept

Prioritization of source control and sequential implementation of airborne precautions for highly infectious respiratory diseases.
Estimated Time:1m 30s
PreviousPage 74 / 195Next
All practice questions — NCLEX-RN | Examkin