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NCLEX-PN Exam Questions - Part 72
1. The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?
A) performing a physical assessment prior to administration
B) obtaining the most recent lab values regarding renal function
C) reviewing peaks and troughs for the past few days
D) ensuring the client is not allergic to the medication
2. The orientation nurse educator reviewing the biohazard legend with a class of new employees states that the emblem is affixed to containers whenever:
A) there is presence of blood and body fluids.
B) there is the need for droplet precaution.
C) there is contact isolation.
D) there is the potential for airborne transmission.
3. The emergency triage nurse should perform which action upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?
A) Place the client in the waiting room until an available cubicle is open.
B) Seclude the client from other clients and visitors.
C) Perform no intervention because it might not be necessary until tests confirm a disease.
D) Don gown, gloves, and mask immediately.
4. Which of the following clients require airborne precautions?
A) a client with fever, chills, vomiting, and diarrhea
B) a client suspected of varicella (chickenpox)
C) a client with abdominal pain and purpura
D) a client diagnosed with AIDS
5. A stool culture reveals Shigella. What corollary should the nurse recognize regarding this bacterial infection?
A) People who have been in contact with the client need to be tested.
B) Shigella is an airborne infection.
C) Shigella is a bacteria sometimes found in stagnant water.
D) The nurse should wear a one-way breathing apparatus when giving client care.
A) performing a physical assessment prior to administration
B) obtaining the most recent lab values regarding renal function
C) reviewing peaks and troughs for the past few days
D) ensuring the client is not allergic to the medication
2. The orientation nurse educator reviewing the biohazard legend with a class of new employees states that the emblem is affixed to containers whenever:
A) there is presence of blood and body fluids.
B) there is the need for droplet precaution.
C) there is contact isolation.
D) there is the potential for airborne transmission.
3. The emergency triage nurse should perform which action upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?
A) Place the client in the waiting room until an available cubicle is open.
B) Seclude the client from other clients and visitors.
C) Perform no intervention because it might not be necessary until tests confirm a disease.
D) Don gown, gloves, and mask immediately.
4. Which of the following clients require airborne precautions?
A) a client with fever, chills, vomiting, and diarrhea
B) a client suspected of varicella (chickenpox)
C) a client with abdominal pain and purpura
D) a client diagnosed with AIDS
5. A stool culture reveals Shigella. What corollary should the nurse recognize regarding this bacterial infection?
A) People who have been in contact with the client need to be tested.
B) Shigella is an airborne infection.
C) Shigella is a bacteria sometimes found in stagnant water.
D) The nurse should wear a one-way breathing apparatus when giving client care.
1. Right Answer: D
Explanation: Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.Safety and Infection Control
2. Right Answer: A
Explanation: When body substances are handled, the potential for transmission is increased; therefore, federal regulations require warning labels to communicate with other employees and/or waste collectors. The biohazard alert is a three-ring symbol overlaying a central concentric ring. Blood, drainage from wounds, feces, and urine are all body fluids that can transfer infection and disease to others. Safety and Infection Control
3. Right Answer: B
Explanation: The client is describing signs and symptoms of tuberculosis. The client is potentially infectious to others and should be secluded. A respirator mask should be worn by caregivers, but it is not necessary for the nurse to don a gown and gloves. If the client is moved to other areas such as radiology, a mask should be worn by the client and a respirator mask should be worn by those working in close contact with the client. Safety and Infection Control
4. Right Answer: B
Explanation: Chickenpox (varicella) is an acute, infectious, airborne illness that requires others in direct contact to wear a respirator mask. Safety and Infection Control
5. Right Answer: C
Explanation: Shigella is a bacteria sometimes found in stagnant water. Transmission of Shigella is typically oral-fecal, so good hand washing and the use of gloves are the best means of prevention when caring for a client with Shigella. The bacteria can be found in food and water contaminated by fecal material. Incidences of Shigella are reportable in many states. Safety and Infection Control
Explanation: Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.Safety and Infection Control
2. Right Answer: A
Explanation: When body substances are handled, the potential for transmission is increased; therefore, federal regulations require warning labels to communicate with other employees and/or waste collectors. The biohazard alert is a three-ring symbol overlaying a central concentric ring. Blood, drainage from wounds, feces, and urine are all body fluids that can transfer infection and disease to others. Safety and Infection Control
3. Right Answer: B
Explanation: The client is describing signs and symptoms of tuberculosis. The client is potentially infectious to others and should be secluded. A respirator mask should be worn by caregivers, but it is not necessary for the nurse to don a gown and gloves. If the client is moved to other areas such as radiology, a mask should be worn by the client and a respirator mask should be worn by those working in close contact with the client. Safety and Infection Control
4. Right Answer: B
Explanation: Chickenpox (varicella) is an acute, infectious, airborne illness that requires others in direct contact to wear a respirator mask. Safety and Infection Control
5. Right Answer: C
Explanation: Shigella is a bacteria sometimes found in stagnant water. Transmission of Shigella is typically oral-fecal, so good hand washing and the use of gloves are the best means of prevention when caring for a client with Shigella. The bacteria can be found in food and water contaminated by fecal material. Incidences of Shigella are reportable in many states. Safety and Infection Control
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