which of the following clients require airborne precautions

NCLEX-PN

Nclex Questions Management of Care

1. Which of the following clients requires 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

Correct answer: B

Rationale: The correct answer is 'a client suspected of varicella (chickenpox).' Chickenpox is an acute, infectious airborne illness that requires airborne precautions, including wearing a respirator mask for direct contact with the patient. Choices A, C, and D do not typically require airborne precautions. Choice A describes symptoms that may indicate a gastrointestinal infection but do not require airborne precautions. Choice C mentions abdominal pain and purpura, which are not specific to an airborne illness. Choice D, a client diagnosed with AIDS, does not necessitate airborne precautions unless there are additional infectious conditions present that require such measures.

2. Under what circumstances is the legal right to confidentiality of client information waived?

A. When a court system subpoenas information.
B. When a family member requests health care information of a client.
C. When a living will takes effect.
D. When the client is declared incompetent by the legal system.

Correct answer: A

Rationale: The legal right to confidentiality of client information is waived when a court system subpoenas information. This occurs when information is required for legal proceedings to occur, such as through summonses, court orders, or litigation information necessary for the court. Subpoenas are legal orders that compel the disclosure of information. The other choices do not inherently waive the legal right to confidentiality. A family member's request for health care information would typically require the client's consent or fall under specific legal exceptions. A living will dictates end-of-life care preferences but does not necessarily waive confidentiality. Lastly, the declaration of incompetence may impact decision-making capacity but does not automatically waive confidentiality.

3. While documenting on a paper form, the nurse realizes they have made a mistake writing the progress note. What should the nurse do?

A. Use a black marker to fully cover up the mistake.
B. Do not make any changes to the progress note but explain later in the note that a mistake was made and note what should have been written.
C. Use whiteout to cover over the mistake and write over it.
D. Inform the client about the mistake and offer to provide a corrected copy.

Correct answer: B

Rationale: In the scenario described, it is essential for the nurse not to alter the original progress note. Option B is the correct course of action as it maintains the integrity of the documentation while acknowledging the error for transparency and accuracy. Using a black marker (Option A) or whiteout (Option C) can be seen as an attempt to conceal the mistake, which is not in line with professional standards. Option D is incorrect because the mistake should be addressed within the documentation itself, not by informing the client directly about it.

4. The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?

A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent.
B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent.
C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room.
D. Proceed with transporting the client to the operating room without obtaining informed consent.

Correct answer: D

Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care. Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.

5. Which of the following represents a normal serum potassium level?

A. 1.5 mEq/L
B. 3.0 mEq/L
C. 4.0 mEq/L
D. 6.0 mEq/L

Correct answer: C

Rationale: The correct answer is 4.0 mEq/L. Normal serum potassium levels typically range from 3.5-5.5 mEq/L. Choice A (1.5 mEq/L) is below the normal range, Choice B (3.0 mEq/L) is also below the normal range, and Choice D (6.0 mEq/L) is above the normal range. Therefore, the only option within the normal range is Choice C (4.0 mEq/L).