Answers 100% Pass
A nurse is caring for a client. The nurse is planning care for the client. Select 4 interventions the nurse
should take.
Client reports fever, fatigue, lack of appetite, and headache that started 2 days ago. Today, client woke up
with blister-like rash all over their face, chest, and back. Client states, "It is beginning to itch and spread."
Lung sounds clear to auscultation. S1, S2, heard no murmur detected. Bowel sounds normoactive in all
quadrants. Notified provider of findings. - ✔✔- place the client in a negative-pressure airflow room
- wear an N95 mask when caring for the client
- designate a stethoscope to be used only on the client
- request a prescription for an antipyretic
Rationale:
- Varicella is transmitted by the air; therefore, airborne isolation precautions need to be taken while caring
for this client.
A nurse is giving a presentation about family violence at a local community center. Which of the
following information should the nurse include?
Socially active parents and guardians are at greater risk for becoming violent.
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,Partner violence occurs more frequently in lower socioeconomic households.
Child maltreatment is more common in homes where partner violence is present.
Children who have been maltreated are less likely to maltreat others. - ✔✔Child maltreatment is more
common in homes where partner violence is present.
Rationale:
Child maltreatment is very common in homes where partner violence is present.
A school nurse is conducting hearing screening procedures in an elementary school. Which of the
following instructions should the nurse provide when performing the Rinne test?
"After I place the tuning fork on your scalp, tell me if you hear the sound better in one ear or the same in
both ears."
"Use your finger to close one ear while I whisper some numbers into your other ear."
"After I place this tuning fork behind your ear, tell me when you no longer hear the sound."
"You'll wear headphones and press the button when you hear a sound." - ✔✔"After I place this tuning
fork behind your ear, tell me when you no longer hear the sound."
Rationale:
This is the appropriate instruction for a Rinne test, a hearing evaluation that compares air conduction and
bone conduction of sound.
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,A nurse on the scene following a mass casualty explosion is triaging a client who has a large, open
occipital wound and the following findings: respiratory rate 6/min, agonal pattern; capillary refill time
4.5 seconds; nonresponsive to painful stimuli. Which of the following actions should the nurse take?
Turn the client to left semi-Fowler's position and begin assessing the next client.
Place a firm pressure dressing to the occiput and open the airway.
Apply a cervical spine collar and perform a focused neurological exam.
Request that the client be assessed immediately by the next available provider. - ✔✔Turn the client to left
semi-Fowler's position and begin assessing the next client.
Rationale:
Principles of triage indicate that clients who have extensive injuries and a low probability of survival do
not receive treatment. Therefore, the nurse should provide only comfort measures before moving on to
assess the next client.
A public health agency has assigned a newly licensed nurse to assist with the task force that is
responsible for the core function of assessment. Which of the following is a task that the public health
agency could assign to the nurse that would be consistent with the focus of the task force?
Updating local policies to support community health efforts
Investigating local health hazards
Collaborating with community agencies to improve availability of services
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, Ensuring competence of health care workforce - ✔✔Investigating local health hazards
Rationale:
Investigating health hazards of the local community is a component of the public health core function of
assessment.
A school nurse is discussing levels of prevention with a teacher. Which of the following activities should
the nurse identify as a primary prevention strategy?
Provide nutritional counseling for students who have diabetes.
Report suspected child neglect to the proper authorities.
Conduct vision and hearing screening for kindergarten enrollment.
Demonstrate proper handwashing techniques. - ✔✔Demonstrate proper handwashing techniques.
Rationale:
This is an example of primary prevention, the goal of which is to promote health and prevent diseases
from developing.
A community health nurse is working to meet the health care needs of residents in a rural community.
Which of the following characteristics should the nurse identify as a barrier to health care resources for
this population?
Less autonomy in providing client care
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