PRACTICE QUESTIONS + ANSWERS
NURSING STUDENTS NZ EXAM
QUESTIONS AND ANSWERS
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 -ANS3. 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 -ANS2. 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.
A client is receiving a unit of packed red blood cells (PRBC). The client experiences
tingling in the fingers and headache. What is the nurses's priority action?
, 1. Call the physician
2.Stop the transfusion
3.Slow the transfusion
4. Assess the IV site for infiltration -ANS2. 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 -ANS3. 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 -ANSTuberculosis 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 for the standard of care for a client diagnosed with TB.
Additionally, opening windows would present a possible safety hazard in a client's room.
A 58-year-old adult client presents to ED with a nosebleed. After applying pressure,
what is the next nursing action?
1.Collect a medical history
NURSING STUDENTS NZ EXAM
QUESTIONS AND ANSWERS
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 -ANS3. 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 -ANS2. 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.
A client is receiving a unit of packed red blood cells (PRBC). The client experiences
tingling in the fingers and headache. What is the nurses's priority action?
, 1. Call the physician
2.Stop the transfusion
3.Slow the transfusion
4. Assess the IV site for infiltration -ANS2. 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 -ANS3. 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 -ANSTuberculosis 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 for the standard of care for a client diagnosed with TB.
Additionally, opening windows would present a possible safety hazard in a client's room.
A 58-year-old adult client presents to ED with a nosebleed. After applying pressure,
what is the next nursing action?
1.Collect a medical history
