Question

The nurse is caring for a client diagnosed with influenza. Which is the most effective action the nurse can teach the client and family members to prevent the spread of infection?

Answer 1

Correct Answers:

Hand hygiene.

Rationale :

💠 Frequent hand hygiene is the single most effective method to reduce transmission of infectious organisms.

💠 Influenza virus spreads via droplets, which easily contaminate hands and surfaces.

💠 Proper technique (using soap and water or alcohol-based sanitizer) removes microorganisms before contact with mucous membranes.

💠 Family and client education on handwashing before meals, after coughing, and after contact prevents cross-infection.

💠 Compliance with hand hygiene standards is the cornerstone of Standard Precautions in infection control.

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Answer 2

Correct Answers:

Vomiting and diarrhea.

Rationale :

🔶 Both vomiting and diarrhea lead to direct loss of water and electrolytes from the GI tract.

🔶 Fluid volume deficit (FVD) occurs when output exceeds intake, causing dehydration.

🔶 Elderly and pediatric clients are most vulnerable due to limited fluid reserves.

🔶 Symptoms include dry mucous membranes, hypotension, and tachycardia.

🔶 Prompt fluid replacement prevents hypovolemic shock and renal impairment.

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Answer 3

Correct Answers:

Urinalysis demonstrates white blood cells (WBCs) and nitrites.
Cloudy unine has a foul odor.
Urinalysis bacterial count greater than 100.000.

Rationale :

🟢 WBCs and nitrites in urine: These indicate bacterial activity and inflammation.

🟢 Cloudy urine with foul odor: Typical of bacterial contamination and pus formation.

🟢 Bacterial count >100,000: Confirms infection rather than simple colonization.

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Answer 4

Correct Answers:

Urinalysis demonstrates white blood cells (WBCs) and nitrites.
Cloudy urine has a foul odor.
Urinalysis bacterial count greater than 100.000.

Rationale :

✳️ White blood cells (WBCs) and nitrites in urine confirm infection presence.

✳️ Cloudy, foul-smelling urine indicates bacterial growth.

✳️ Bacterial count >100,000 CFU in urinalysis supports a diagnosis of UTI.

✳️ Catheter-associated UTIs occur from improper sterile technique or prolonged use.

✳️ Prompt recognition prevents ascending infection or sepsis.

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Answer 5

Correct Answers:

Use sterile technique when inserting an indwelling urinary catheter.
Perform hand hygiene before client care, after a body fluid exposure, and offer client care
Mantana dan environment by thinnecting surtaces and equipment

Rationale :

💠 Sterile technique prevents infection during catheter insertion.

💠 Hand hygiene before and after patient care limits microorganism transfer.

💠 Disinfecting surfaces and equipment maintains a clean care environment.

💠 These practices reduce healthcare-associated infection risk.

💠 Implementation follows standard precautions and infection control policies.

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Answer 6

Correct Answers:

Discontinue the IV promptly.

Rationale :

🟢 Redness and warmth at IV site suggest phlebitis or vein inflammation.

🟢 Removing the IV prevents further irritation and infection spread.

🟢 Documenting and notifying provider ensures safe follow-up care.

🟢 Warm compresses may then be applied for comfort.

🟢 New IV should be inserted in an unaffected extremity.

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Answer 7

Correct Answers:

Place the client in high-Fowler position, ensure an open (patent) airway, and anticipate administration of supplemental oxygen.

Rationale :

♦ This position maximizes lung expansion and improves oxygenation.

♦ Ensuring a patent airway is the top priority in respiratory distress.

♦ Supplemental oxygen supports gas exchange and prevents hypoxemia.

♦ Early positioning can reduce the need for mechanical ventilation.

♦ The nurse must remain with the patient and monitor respiratory rate and effort.

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Answer 8

Correct Answers:

Urinating dark amber urine throughout the day.
Shortness of breath.
An acute change in mental status.
SpO2 (oxygen saturation) of 92% on room air.

Rationale :

🔶 Dark amber urine shows dehydration or renal impairment.

🔶 Shortness of breath requires urgent respiratory evaluation.

🔶 Change in mental status signals poor oxygenation or metabolic imbalance.

🔶 SPO₂ of 92% indicates mild hypoxia requiring intervention.

🔶 Prompt response prevents worsening oxygen deficiency and organ dysfunction.

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Answer 9

Correct Answers:

Stoma is purple blue in color.

Rationale :

✍️ A purple or blue stoma indicates poor blood flow or ischemia.

✍️ This is an emergency requiring immediate provider notification.

✍️ A healthy stoma should appear pink to red and moist.

✍️ Ischemia can progress to necrosis if unaddressed.

✍️ Monitoring color and moisture ensures stoma viability.

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Answer 10

Correct Answers:

Inhale as slowly and as deeply as possible through the mouthpiece without using the nose.

Rationale :

🔵 Incentive spirometry promotes lung expansion and alveolar inflation.

🔵 Slow inhalation ensures air reaches lower lung bases, preventing atelectasis.

🔵 Avoiding nasal inhalation ensures accurate volume measurement.

🔵 This exercise enhances oxygenation and prevents pneumonia.

🔵 The nurse should encourage use hourly while awake postoperatively.

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NSG 131 Exam 2

No.

1 :
The nurse is caring for a client diagnosed with influenza. Which is the most effective action the nurse can teach the client and family members to prevent the spread of infection?

2 :
A nurse is caring for a group of clients. Which client problem would the nurse identify as a high risk for fluid volume deficit?

3 :
The nurse is caring for a client with a suspected indwelling urinary catheter associated urinary tract infection. Which findings indicate the suspected infection? Select all that apply.

4 :
The nurse is caring for a client with a suspected indwelling urinary catheter associated urinary tract infection. Which findings indicate the suspected infection? (Select all that apply.)

5 :
The nurse is planning interventions for a client at risk for infection. What nursing actions should be included in the plan? Select all that apply

6 :
A nurse is caring for a client with phlebitis. The nurse notices that the IV site that has Normal Saline infusing has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?

7 :
Which action does the nurse take first when the client begins to demonstrate clinical manifestations of respiratory distress?

8 :
Which clinical manifestations would prompt the nurse to immediate intervention? (Select All that Apply

9 :
A nurse is caring for a client who had a colostomy placed 24 hours ago. The nurse would report which ostomy-related assessment finding to the provider immediately?

10 :
A nurse is teaching a postoperative client how to use an incentive spirometer. Which instruction should be included in the teaching?

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NSG 131 Exam 2

No.

1 : The nurse is caring for a client diagnosed with influenza. Which is the most effective action the nurse can teach the client and family members to prevent the spread of infection?

2 : A nurse is caring for a group of clients. Which client problem would the nurse identify as a high risk for fluid volume deficit?

3 : The nurse is caring for a client with a suspected indwelling urinary catheter associated urinary tract infection. Which findings indicate the suspected infection? Select all that apply.

4 : The nurse is caring for a client with a suspected indwelling urinary catheter associated urinary tract infection. Which findings indicate the suspected infection? (Select all that apply.)

5 : The nurse is planning interventions for a client at risk for infection. What nursing actions should be included in the plan? Select all that apply

6 : A nurse is caring for a client with phlebitis. The nurse notices that the IV site that has Normal Saline infusing has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?

7 : Which action does the nurse take first when the client begins to demonstrate clinical manifestations of respiratory distress?

8 : Which clinical manifestations would prompt the nurse to immediate intervention? (Select All that Apply

9 : A nurse is caring for a client who had a colostomy placed 24 hours ago. The nurse would report which ostomy-related assessment finding to the provider immediately?

10 : A nurse is teaching a postoperative client how to use an incentive spirometer. Which instruction should be included in the teaching?

1 :
The nurse is caring for a client diagnosed with influenza. Which is the most effective action the nurse can teach the client and family members to prevent the spread of infection?

2 :
A nurse is caring for a group of clients. Which client problem would the nurse identify as a high risk for fluid volume deficit?

3 :
The nurse is caring for a client with a suspected indwelling urinary catheter associated urinary tract infection. Which findings indicate the suspected infection? Select all that apply.

4 :
The nurse is caring for a client with a suspected indwelling urinary catheter associated urinary tract infection. Which findings indicate the suspected infection? (Select all that apply.)

5 :
The nurse is planning interventions for a client at risk for infection. What nursing actions should be included in the plan? Select all that apply

6 :
A nurse is caring for a client with phlebitis. The nurse notices that the IV site that has Normal Saline infusing has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?

7 :
Which action does the nurse take first when the client begins to demonstrate clinical manifestations of respiratory distress?

8 :
Which clinical manifestations would prompt the nurse to immediate intervention? (Select All that Apply

9 :
A nurse is caring for a client who had a colostomy placed 24 hours ago. The nurse would report which ostomy-related assessment finding to the provider immediately?

10 :
A nurse is teaching a postoperative client how to use an incentive spirometer. Which instruction should be included in the teaching?