which of the following teaching topics should the nurse discuss when working with an immunocompromised client

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. Which of the following safety precautions should the nurse discuss when working with an immunocompromised client?

A. Avoid canned foods and increase consumption of fresh fruits and vegetables
B. Hand-wash utensils after use and allow them to air dry
C. Only drink tap water that has been filtered or boiled before consumption
D. Never eat meals prepared in restaurants

Correct answer: C

Rationale: The correct answer is to only drink tap water that has been filtered or boiled before consumption. Immunocompromised clients are susceptible to infections, so it is essential to take precautions to prevent exposure to harmful pathogens. Drinking tap water that has been filtered or boiled helps eliminate potential pathogens that could be harmful to the client's health. Choices A, B, and D do not directly address the issue of avoiding potential pathogens that could compromise the health of an immunocompromised client. Thus, they are incorrect. Hand-washing utensils, avoiding canned foods, and increasing fruit and vegetable consumption are good general hygiene practices but may not specifically address the needs of an immunocompromised client.

2. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

A. UAP splint the patient's chest during coughing.
B. UAP assist the patient to ambulate to the bathroom.
C. UAP help the patient to a bedside chair for meals.
D. UAP lower the head of the patient's bed to 15 degrees.

Correct answer: D

Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.

3. An experienced healthcare professional instructs a new colleague on caring for a patient with dyspnea due to a pulmonary fungal infection. Which action by the new colleague indicates a need for further teaching?

A. Listening to the patient's lung sounds several times during the shift
B. Placing the patient in droplet precautions and in a private hospital room
C. Increasing the oxygen flow rate to maintain oxygen saturation above 90%
D. Monitoring the patient's serology results to identify the specific infecting organism

Correct answer: B

Rationale: The correct answer is placing the patient in droplet precautions and in a private hospital room. Fungal infections are not transmitted from person to person, so isolation procedures like droplet precautions are unnecessary. Listening to the patient's lung sounds, increasing the oxygen flow rate, and monitoring serology results are all appropriate actions in caring for a patient with dyspnea caused by a pulmonary fungal infection.

4. In which situation would the nurse use bimanual palpation technique?

A. Palpating the thorax of an infant
B. Palpating the kidneys and uterus
C. Assessing pulsations and vibrations
D. Assessing the presence of tenderness and pain

Correct answer: B

Rationale: Bimanual palpation involves using both hands to envelop or capture specific body parts or organs like the kidneys, uterus, or adnexa. This technique is particularly useful for assessing the size, shape, consistency, and mobility of deep organs like the kidneys and uterus. Palpating the thorax of an infant (Choice A) is usually done with a different technique like gentle, single-handed palpation. Assessing pulsations and vibrations (Choice C) and assessing tenderness and pain (Choice D) typically do not require the use of bimanual palpation, making Choices A, C, and D incorrect.

5. What is the BEST blood collection location for a newborn?

A. the AC
B. the veins of the forehead
C. the heel
D. the fingertips

Correct answer: C

Rationale: When collecting blood from newborns, it is safest and most commonly done by collecting blood from the lateral or medial aspect of the baby's heel. This location is preferred due to the accessibility of the veins and the minimal discomfort caused to the newborn. Veins in the forehead are not commonly used for blood collection in newborns. The fingertips are not optimal for blood collection in newborns due to their small size and the potential for causing discomfort. The AC (antecubital) area, typically used in adults for blood collection, is not recommended for newborns due to the size of their veins and the potential risk of injury.