in addition to standard precautions the nurse caring for a patient with rubella would plan to implement what type of precautions
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Nursing Elites

NCLEX-RN

NCLEX RN Predictor Exam

1. In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions?

Correct answer: A

Rationale: Rubella is an illness transmitted by large-particle droplets, so the nurse should implement droplet precautions in addition to standard precautions. Airborne precautions are used for diseases spread through small particles in the air, such as tuberculosis, varicella, and rubeola. Contact precautions are utilized for diseases transmitted by direct contact with the patient or their environment. Universal precautions and body substance isolations are part of the CDC's standard precautions recommendations, but do not specifically address the transmission route of rubella.

2. The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?

Correct answer: A

Rationale: In this scenario, the nurse is cautious about potential diagnostic errors due to incomplete data. When a client withholds information, it can lead to incomplete data, which may result in inaccurate nursing diagnoses and care planning. Therefore, the nurse's primary concern is collecting accurate data to make informed clinical decisions. Choices B, C, and D are not relevant to the situation described. Generalizing from experience, identifying with the client, and lack of clinical experience do not directly address the issue of incomplete data impacting the diagnostic process.

3. Which of the following is an example of an environmental hazard that may put the healthcare professional at risk of injury?

Correct answer: D

Rationale: Healthcare professionals, including nurses, are exposed to various environmental hazards that may negatively impact their physical or mental health. Hazards come in several forms, such as loud noise from hospital systems, which can damage hearing; airborne latex powder, leading to allergic reactions; and chemicals like ethylene oxide, a sterilizing agent that can cause cancer. Therefore, all the options listed pose risks to healthcare professionals, making 'All of the above' the correct answer. Choice A, loud noise, is a hazard that can affect hearing health. Choice B, airborne latex powder, can trigger allergic responses. Choice C, chemicals containing ethylene oxide, are hazardous and can lead to serious health issues. Each option represents a distinct environmental risk that healthcare professionals should be aware of and take precautions against.

4. How does the procedure for taking a pulse rate on an infant differ from an adult?

Correct answer: B

Rationale: The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately. Choices A, C, and D are incorrect. Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method. Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates. Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.

5. Which body plane divides the body into right and left sides?

Correct answer: C

Rationale: The correct answer is the Median Plane, also known as the sagittal plane. It divides the body into right and left sides. The Frontal Plane, or coronal plane, divides the body into front and back sections. The Transverse Plane divides the body into superior (upper) and inferior (lower) sections. Therefore, choices A, B, and D are incorrect as they do not specifically divide the body into right and left sides.

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