a nurse is planning care for a client who has tuberculosis which of the following actions should the nurse take to prevent the transmission of the dis

ATI RN

ATI RN Comprehensive Exit Exam

1. A nurse is planning care for a client who has tuberculosis. Which of the following actions should the nurse take to prevent the transmission of the disease?

A. Place the client in droplet isolation.
B. Place the client in airborne isolation.
C. Wear a surgical mask when providing care to the client.
D. Keep the client's door closed at all times.

Correct answer: B

Rationale: The correct answer is B: 'Place the client in airborne isolation.' Tuberculosis is an airborne disease transmitted through droplet nuclei. Placing the client in airborne isolation helps prevent the spread of the disease to others. Choice A, placing the client in droplet isolation, is incorrect because tuberculosis is not transmitted through large droplets. Choice C, wearing a surgical mask when providing care to the client, is not sufficient as airborne precautions are necessary. Choice D, keeping the client's door closed at all times, does not directly address the prevention of disease transmission in this case.

2. What is the priority intervention for a patient with dehydration?

A. Administer IV fluids
B. Monitor intake and output
C. Administer oral fluids
D. Provide electrolyte replacement

Correct answer: A

Rationale: The correct answer is to administer IV fluids. This intervention is the priority as it helps rapidly restore hydration in patients with dehydration by delivering fluids directly into the bloodstream. Monitoring intake and output (choice B) is important but comes after providing immediate fluid resuscitation. Administering oral fluids (choice C) may not be sufficient for a patient with dehydration who requires rapid rehydration. Providing electrolyte replacement (choice D) is essential but often follows fluid resuscitation to correct any electrolyte imbalances resulting from dehydration.

3. What is the most important nursing action for a patient post-surgery?

A. Monitor vital signs
B. Monitor the surgical site
C. Check blood pressure
D. Check oxygen saturation

Correct answer: A

Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.

4. A nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair. Which of the following findings should the nurse report to the provider?

A. Heart rate of 88/min
B. Pain rating of 4 on a scale of 0 to 10
C. Blood pressure 110/70 mm Hg
D. Urine output of 20 mL/hr

Correct answer: D

Rationale: A low urine output of 20 mL/hr, less than the expected 30 mL/hr or more, could indicate renal impairment or inadequate fluid status postoperatively. In this scenario, early detection and intervention are crucial to prevent further complications. The other findings - heart rate of 88/min, pain rating of 4, and blood pressure of 110/70 mm Hg - are within normal limits for a client 2 hr postoperative following an inguinal hernia repair and do not raise immediate concerns.

5. A healthcare professional is preparing to administer ceftriaxone IM to a client. Which of the following actions should the healthcare professional take?

A. Administer the medication using a tuberculin syringe
B. Administer the medication at a 45-degree angle
C. Use the dorsogluteal muscle for injection
D. Aspirate for blood return before injecting the medication

Correct answer: D

Rationale: Correct Answer: When administering intramuscular injections like ceftriaxone, it is essential to aspirate for blood return before injecting the medication to ensure that the needle is not in a blood vessel. Choices A and B are incorrect because ceftriaxone is typically administered using a syringe appropriate for IM injections (not a tuberculin syringe) and injected at a 90-degree angle rather than 45 degrees. Choice C is incorrect because the dorsogluteal site is no longer recommended for IM injections due to potential injury to the sciatic nerve and other structures.