the nurse is preparing an airborne infection isolation room for a patient which communicable disease does the patient likely have the nurse is preparing an airborne infection isolation room for a patient which communicable disease does the patient likely have
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Nursing Elites

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Nursing Care of Children ATI

1. The nurse is preparing an airborne infection isolation room for a patient. Which communicable disease does the patient likely have?

Correct answer: A

Rationale: Varicella (chickenpox) is an airborne infectious disease, requiring isolation to prevent the spread of the virus.

2. A client has been diagnosed with generalized anxiety disorder and expresses worrying about their job, family, and health, feeling a loss of control. What should the nurse do first?

Correct answer: D

Rationale: The initial step for the nurse is to teach the client deep breathing techniques to aid in managing anxiety symptoms. Deep breathing exercises can help the client relax, reduce anxiety levels, and regain a sense of control. This intervention is non-invasive, empowering the client to develop a coping strategy for immediate use when feeling overwhelmed by anxiety. Administering medication (Choice A) should not be the first action unless the client is in severe distress. Encouraging attendance at a support group (Choice B) and identifying triggers of anxiety (Choice C) are important but teaching coping strategies like deep breathing comes first to help the client feel more in control of managing their anxiety.

3. When documenting an incorrect dose of medication administered, which fact related to the incident report should the nurse document in the client's medical record?

Correct answer: A

Rationale: The nurse should document the time the medication was given in the client's medical record when an incorrect dose is administered. Recording the time is crucial for establishing the sequence of events accurately. Choices B, C, and D, though important, are not directly relevant to documenting the incident of administering an incorrect dose of medication. The client's response to the medication, the actual dose administered, and the reason for the error may be documented for overall patient care but are not specifically required in the incident report for an incorrect dose.

4. After a subtotal gastrectomy, the nurse should anticipate that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?

Correct answer: A

Rationale: Dark brown drainage is expected for about 12 to 24 hours after surgery.

5. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

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