Nursing Students NZ Exam Graded A+.
The nurse receives a report on a newly admitted client who is positive for Clostridium difficile.
Which category of isolation would the nurse implement for this client?
1. Airborne precautions
2. Droplet precautions
3. Contact precautions
4. Protective environment - Answer 3. Contact precautions
Rationale: Used for direct client or environmental contact with blood or body fluids from an
infected client. This includes colonization of infection with multidrug-resistant organisms
(MDRO) such as MRSA, stool infected with Clostridium difficle, draining wounds where
secretions are not contained, or scabies. Airborne precautions (1) are used for infected droplets
smaller then 5mcg, such as measles, chickenpox (varicella), or pulonary TB. Droplet precautions
(2) are used for droplets larger than 5mcg and being within 3 feet of the client, such as
streptococcal pharyngitis, mumps, and influneza. Protective environment (4) focuses on client
with a compromised immune system to protect them from incoming pathogens.
A client who is HIV pos is admitted to a surgical unit after an orthopedic procedure. The nurse
should institute appropriate precautions knowing that HIV is highly transmitted through
1. feces
2. blood
3. semen
4. urine
5. sweat
6. tears - Answer 2. Blood, 3. Semen
HIV, which is the virus that causes AIDS, is transmitted through infected blood, semen, and
bloody body fluids. HIV is not spread casually. Although HIV may be found in other body
secretions, including faces (1), urine (4), sweat (5), tears (6), saliva, sputum, and emesis, the
amount of virus is likely not sufficient enough to be transmitted.
, 2.Stop the transfusion
3.Slow the transfusion
4. Assess the IV site for infiltration - Answer 2. Stop the transfusion
Tingling in the fingers and headache may be an indication of an adverse reaction to the
transfusion. The nurse's priority action is to stop the transfusion and begin a normal saline
infusion at KVO (keep vein open). The client should be assessed-including vital signs - then the
physician should be notified. The physician should be called (1) after assessment of the patient
and implementation of immediate action to stop the transfusion. Slowing the infusion rate (3) is
not appropriate if the patient is experiencing a reaction or suspected of having an reaction.
Assessment of the IV site (4) is part of the general patient assessment and is not related to a
blood transfusion reaction
A client is ordered to receive morphine via patient-controlled analgesia (PCA). Before beginning
administration of this medication, what should the nurse assess first?
1.Temperature
2.Neurological status
3. Respiration
4.Urinary ouput - Answer 3. Respiration
The nurse must be especially alert to any changed in respirations, because morphine decreases
the respiratory center function in the brain. An order for morphine should be questioned if the
baseline respiration are less than 12 per min. Neurological status (2) along with pulse and BP
would be a priority assessment after respiratory rate. Measurements of temperature (1) and
urinary output (4) are part of the overall client assessment but not a priority with morphine.
A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which
type of room should this client be assigned by the nurse?
1. Private room
2. Semiprivate room
3. Room with windows that can be opened
4. Negative airflow room - Answer Tuberculosis is an airborne contagious disease that is best
contained in a negative airflow room. Negative airflow rooms are always private. A private room
(1), Semipriavte room (2), and a room with windows that can be opened (3) are not appropriate