2024 TEST BANK 270 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
A nurse is assisting with the admission of a client who
has active tuberculosis. Which of the following actions
should the nurse plan to take?
A. Restrict the client's visitors to the immediate family.
B. Assign the client to a negative-pressure airflow
room.
C. Discard personal protective equipment outside the
client's room.
D. Have the client wear a HEPA mask during
transportation throughout the facility. -
...ANSWER...B. Assign the client to a negative-
pressure airflow room.
RATIONALE: The nurse should assign the client to a
negative-pressure airflow room to ensure that the air
from the client's room is not circulated throughout the
facility.
A nurse is assisting with the plan of care for a client
who has a bacterial infection and a persistent oral
temperature of 38.9° C (102° F). Which of the
following interventions should the nurse include in the
plan of care to treat the fever?
A. Administer acetaminophen.
,B. Apply ice packs to the client's axillae.
C. Maintain the room temperature at 18.3° C (64.9° F).
D. Assist the client to ambulate four times a day. -
...ANSWER...A. Administer acetaminophen.
RATIONALE: The nurse should administer
acetaminophen or an NSAID such as ibuprofen to the
client to reduce the body's temperature.
Acetaminophen inhibits the synthesis of
prostaglandins, resulting in a reduced fever.
A nurse is contributing to the plan of care for a client
who has a positive throat culture for streptococci.
Which of the following interventions should the nurse
recommend to be included in the plan of care?
A. Place the client in a room with another client who
has pharyngitis.
B. Ensure that the client wears a surgical mask during
transportation throughout the facility.
C. Limit the client's visitors to visitations of 30 min.
D. Provide the client a room with negative-pressure
airflow of six air exchanges per hour. -
...ANSWER...B. Ensure that the client wears a
surgical mask during transportation throughout the
facility.
RATIONALE: Streptococcal pharyngitis requires
droplet precautions. The nurse should instruct the
client to wear a surgical mask when outside of the
room to prevent the spread of infection. Staff should
make every attempt to limit the client's movement
outside of the room.
,A nurse is planning care for a client who is disoriented
and at risk for falls. Which of the following
interventions should the nurse include? (Select all that
apply.)
A. Ensure that the client is wearing nonskid slippers.
B. Move the bedside table away from the bedside.
C. Place the client in a room near the nurses' station.
D. Keep the bed's full side rails in the up position.
E. Reinforce teaching about how to use the call bell. -
...ANSWER...A. Ensure that the client is wearing
nonskid slippers.
Nonskid slippers provide better traction and can help
prevent slipping and falling.
C. Place the client in a room near the nurses'
station. Keeping the client close to the nurses'
station
for moreallows
frequent observation to help identify actions
that increase the risk for falls.
E. Reinforce teaching about how to use the call bell.
Even if the client is confused, it is important to
reinforce the use of the call bell for assistance to help
prevent the client from attempting actions that could
increase the risk for falls.
A nurse is contributing to a plan of care for a client
who has a new prescription for a wrist restraint. Which
of the following actions should the nurse include in the
plan?
A. Check that the restraint is tied to a fixed frame of
the bed.
B. Pad bony prominences on the wrist.
, C. Remove the restraint every 4 hr to allow movement.
D. Tie the restraint with a knot that will tighten when
pulled. - ...ANSWER...B. Pad bony prominences on
the wrist.
RATIONALE: The nurse should pad bony
prominences on the wrist to prevent skin breakdown
caused by the restraint rubbing against the client's
skin.
A nurse is reinforcing teaching with a client who has
a partial hearing loss about how to modify the home
environment. Which of the following is a priority
modification that the nurse should include?
A. Alarm clock that shakes the bed
B. Flashing smoke alarm
C. Low-pitched buzzer doorbell
D. Telephone with an amplified receiver -
...ANSWER...B. Flashing smoke alarm
RATIONALE: The greatest risk to the client's safety is
injury from a fire. Therefore, the priority modification is
to install flashing smoke alarms because this allows
the client to see when the alarm is activated rather
than having to hear it.
A nurse is caring for four clients who are required to
provide informed consent for treatment. The nurse
should identify that which of the following clients is
able to provide informed consent?
A. A client who is receiving opioid medications via a
PCA pump
B. A client who has moderate Alzheimer's disease