Choice A rationale:

Confine the fire by closing doors and windows. While confining the fire is important, the nurse's first priority should be ensuring the safety of the client. Closing doors and windows may help prevent the fire from spreading, but it does not address the immediate danger to the client.

Choice B rationale:

Activate the fire alarm system. Activating the fire alarm is a crucial step to alert other staff members, patients, and visitors about the fire. However, it is not the first action the nurse should take. Ensuring the safety of the client should be the top priority.

Choice C rationale:

Extinguish the fire if possible. Attempting to extinguish the fire can be dangerous for the nurse and may waste precious time. The nurse's safety and the client's safety should be the primary concern. Trying to put out the fire before ensuring the client's safety is not the best course of action.

Choice D rationale:

Rescue the client from immediate danger. This is the correct answer because the nurse's first priority in a fire emergency is to ensure the safety of the client. Rescuing the client from immediate danger should be done before any other actions are taken. The nurse should assess the situation, help the client to safety, and then notify others about the fire and activate the alarm system.

Choice A rationale:

Retie the restraint straps with a slipknot. Using a slipknot may make it easier to release the restraints quickly if necessary, but it does not address the issue of proper fit and safety. The nurse should focus on ensuring the restraints are applied correctly and safely.

Choice B rationale:

Check that three fingers will fit beneath the restraints. This is the correct answer because it ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. Checking for proper fit is a fundamental safety measure when using restraints.

Choice C rationale:

Retie the restraint straps to the side rails. Tying the restraints to the side rails could pose a significant risk to the client's safety. It may restrict movement further and lead to complications. The nurse should prioritize the client's comfort and safety when applying restraints.

Choice D rationale:

Remove the padding under the wrist restraints. Removing the padding under the restraints may cause discomfort and skin irritation for the client. Properly padded restraints are necessary to prevent injury. Instead of removing the padding, the nurse should focus on checking the fit and ensuring the restraints are applied correctly.

Choice A rationale:

Use a fire extinguisher on the outlet. Using a fire extinguisher directly on an electrical outlet is extremely dangerous and can lead to electrocution. It is not a recommended action in this situation.

Choice B rationale:

Activate the fire alarm. This is the correct answer because activating the fire alarm alerts others in the facility about the fire, allowing for a swift and organized evacuation. Alerting others to the danger is essential in ensuring everyone's safety during a fire emergency.

Choice C rationale:

Move any clients to safety. While moving clients to safety is important, activating the fire alarm should be the first action taken. Alerting others about the fire enables a coordinated response and ensures that everyone is aware of the emergency situation.

Choice A rationale:

Confine the fire by closing doors and windows. Rationale: While confining the fire is essential, the nurse's first priority should be the safety of the client. Closing doors and windows can wait. The nurse should focus on immediate actions to ensure the client's safety.

Choice B rationale:

Activate the fire alarm system. Rationale: Activating the fire alarm system is crucial to alert others in the healthcare facility about the fire. This action ensures a timely response from the fire department and other staff members, enhancing overall safety within the facility.

Choice C rationale:

Extinguish the fire if possible. Rationale: Attempting to extinguish the fire might lead to delay, especially if the nurse is not trained to handle fires properly. Moreover, the nurse's safety is paramount, and attempting to put out the fire could put the nurse at risk. Prioritizing the client's immediate rescue is the best course of action.

Choice D rationale:

Rescue the client from immediate danger. Rationale: The correct action for the nurse to take first is to rescue the client from immediate danger. This may involve helping the client out of the room or moving them away from the source of the fire. Ensuring the client's safety is the top priority, and all other actions should follow after this.

Choice A rationale:

Retie the restraint straps with a slipknot. Rationale: If the restraints are too tight or uncomfortable for the client, adjusting them is essential. However, the slipknot is not the appropriate method. The nurse should ensure that the restraints are secure but not too tight, allowing for proper circulation and comfort for the client.

Choice B rationale:

Check that three fingers will fit beneath the restraints. Rationale: This is the correct action. The nurse should assess the tightness of the restraints by checking if three fingers can fit beneath them. This method ensures that the restraints are secure enough to prevent the client from removing them but not so tight that they compromise the client's circulation or skin integrity.

Choice C rationale:

Retie the restraint straps to the side rails. Rationale: Tying the restraints to the side rails is not a safe practice. It can cause injury to the client and is a restraint-related risk. Restraints should be tied to the bed frame, not the side rails, to ensure proper safety measures are followed.

Choice D rationale:

Remove the padding under the wrist restraints. Rationale: The padding under the wrist restraints provides comfort and prevents skin irritation. Removing the padding is not necessary unless it is soiled or damaged. The nurse should focus on ensuring that the restraints are appropriately secured and not causing harm to the client.

Choice A rationale:

Use a fire extinguisher on the outlet. Rationale: Using a fire extinguisher directly on an electrical outlet is dangerous and can lead to electrical shock. It is not the appropriate action to take in this situation. The nurse should prioritize safety and avoid actions that could cause harm to themselves or others.

Choice B rationale:

Activate the fire alarm. Rationale: This is the correct action. Activating the fire alarm alerts others in the facility, allowing for a swift response from the fire department and evacuation procedures to be initiated. Ensuring that everyone is aware of the emergency is essential for a coordinated and safe evacuation.

Choice C rationale:

Move any clients to safety. Rationale: While moving clients to safety is important, it is not the nurse's first priority in this scenario. Activating the fire alarm should come first to ensure a quick response from emergency services and to alert all staff and patients about the fire. Once the alarm is activated, moving clients to safety can be the next appropriate step.

Choice A rationale:

Using a fire extinguisher should not be the nurse's first action in this situation. The nurse's priority is to ensure the safety of the clients and staff in the vicinity. Attempting to use a fire extinguisher might not be effective and can potentially cause harm, especially if the fire spreads quickly.

Choice B rationale:

Activating the fire alarm is the nurse's priority in this situation. By activating the fire alarm, the nurse can alert everyone in the facility about the fire, ensuring that people are aware and can evacuate safely. This action initiates the facility's fire response protocol, leading to a quicker and organized response to the emergency.

Choice C rationale:

Moving clients to safety is important, but it is not the nurse's immediate priority in this situation. Activating the fire alarm should be done first to ensure that everyone in the facility is aware of the danger, and then the nurse can assist in moving clients to safety if necessary.

Choice A rationale:

Instructing the clients to use the call light is an important action to prevent falls. If the clients need assistance or have to leave their beds, they should use the call light to alert the nurse or healthcare provider. Prompt response to call lights can prevent clients from attempting to move on their own and potentially falling.

Choice B rationale:

Keeping the clients' rooms dark is not a safe practice, especially for clients at risk for falls. Dim lighting can increase the risk of tripping or falling, especially during nighttime when visibility is already reduced. Adequate lighting in the clients' rooms is essential to ensure their safety.

Choice C rationale:

Moving overbed tables away from the bed is crucial in preventing falls. Overbed tables can obstruct the clients' movement, leading to accidents. By keeping the area around the bed clear, the clients have more space to maneuver safely, reducing the risk of falls.

Choice D rationale:

Performing client checks every 4 hours is a good practice, but it is not sufficient for clients at high risk for falls, especially during the night shift when they may need assistance to use the bathroom or move in bed. Frequent checks and availability to assist clients promptly are essential to prevent falls effectively.

Choice A rationale:

"I will keep my walker at the end of my bed." This statement indicates that the client understands the importance of having the walker within reach. Placing the walker at the end of the bed ensures that the client can use it immediately upon getting up, providing support and stability, thus reducing the risk of falls.

Choice B rationale:

"I will keep the fluorescent ceiling light on in my room at night." While having adequate lighting is important, using a fluorescent ceiling light throughout the night might disrupt the client's sleep. Additionally, a nightlight or a bedside lamp with a low-wattage bulb can provide sufficient illumination without disturbing sleep.

Choice C rationale:

"I will place an area rug at the entry of my bathroom." This statement indicates a lack of understanding. Area rugs can be tripping hazards, especially in areas prone to moisture like bathrooms. It is advisable to remove rugs and ensure non-slip flooring to prevent slips and falls.

Choice D rationale:

"I will place a bath seat in my shower to use when I bathe." While using a bath seat is a good safety measure, it does not address the client's risk of falling outside the shower area. Installing grab bars and non-slip mats in the bathroom, along with removing potential hazards, would be more comprehensive in ensuring the client's safety. .

Choice A rationale:

Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.

Choice B rationale:

Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.

Choice C rationale:

Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.

Choice D rationale:

Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.

Choice A rationale:

Squeezing the handles together is incorrect. This action alone does not activate the fire extinguisher and will not help in extinguishing the fire. Proper operation of a fire extinguisher involves specific steps to effectively put out the fire.

Choice B rationale:

Pulling the pin found between the handles is a necessary step, but it is not the first step. Before pulling the pin, the nurse should aim the nozzle at the base of the flames to ensure effective fire suppression.

Choice C rationale:

Aiming the nozzle at the base of the flames is the first step. Directing the extinguisher nozzle at the base of the fire is crucial because it targets the source of the flames. By doing so, the nurse can smother the fire and prevent it from spreading further.

Choice D rationale:

Sweeping the nozzle back and forth at the base of the flames is the correct technique after aiming the nozzle at the base of the fire. This sweeping motion helps cover the entire area of the fire and ensures that all flames are properly extinguished.

Choice A rationale:

Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.

Choice B rationale:

Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.

Choice C rationale:

Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.

Choice D rationale:

Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.

Choice A rationale:

Family members who smoke must be at least 10 ft from the client when oxygen is in use. Oxygen supports combustion, and smoking near an oxygen source can lead to a fire. Keeping family members who smoke at a safe distance minimizes this risk.

Choice B rationale:

Nail polish remover or hair spray should not be used near a client who is receiving oxygen. These substances contain flammable ingredients, which can ignite in the presence of oxygen. Instructing the client and those around them to avoid using such products prevents potential accidents.

Choice C rationale:

A "No Smoking" sign should be placed on the front door. This serves as a visual reminder to visitors and family members that smoking is prohibited in the vicinity, reducing the risk of fire when oxygen is in use. Clear communication through signage is essential in maintaining a safe environment.

Choice E rationale:

A fire extinguisher should be readily available in the home. Despite precautions, accidents can still happen. Having a fire extinguisher nearby allows for immediate response in case of a fire-related emergency, ensuring the safety of the client and those around them.

Choice D rationale:

Cotton bedding and clothing should be replaced with items made from wool. This statement is incorrect. There is no specific requirement to replace cotton items with wool for a client using oxygen. Instead, the focus should be on fire safety measures and ensuring that flammable materials are kept away from the oxygen source.

Choice B rationale:

Call for additional staff to assist with the transfer. The nurse's priority in this situation is ensuring the safety of the client during the transfer from the chair to the bed. Calling for additional staff provides the necessary support to safely move the client, minimizing the risk of falls or injuries. It is crucial to have an adequate number of staff members to assist in transfers, especially when the client's mobility is compromised.

Choice A rationale:

Obtain a walker for the client to use to transfer back to bed. While a walker can be helpful for mobility, the client has already asked to return to bed, indicating the immediate need for assistance. Waiting to obtain a walker could delay the transfer, potentially putting the client at risk.

Choice C rationale:

Use a transfer belt and assist the client back into bed. Using a transfer belt is a suitable technique for assisting clients with mobility. However, the nurse's priority in this scenario is to ensure there is enough staff assistance to guarantee a safe transfer. The nurse should not attempt to perform the transfer alone, even with a transfer belt, as it might be unsafe for both the nurse and the client.

Choice D rationale:

Determine the client's ability to help with the transfer. While assessing the client's ability to participate in the transfer is important, it is not the nurse's priority in this situation. The immediate concern is to secure adequate assistance to safely move the client back to bed.

Choice A rationale:

Fall history. A client's previous falls provide valuable information about their risk factors, helping the nurse assess the likelihood of future falls. A history of falls indicates an increased risk and requires appropriate preventive measures.

Choice B rationale:

Medical diagnosis. Certain medical conditions and diseases can affect a client's balance, coordination, and overall mobility, increasing their susceptibility to falls. Understanding the client's medical diagnosis is crucial for assessing fall risk accurately.

Choice C rationale:

Use of assistive devices. Clients who use assistive devices like walkers, canes, or wheelchairs are at risk of falls if these devices are not used correctly or are in disrepair. Assessing the condition and proper use of assistive devices is essential in evaluating fall risk.

Choice D rationale:

Mental status. Cognitive impairment, confusion, or disorientation can significantly contribute to falls. Clients with altered mental status may have difficulty recognizing hazards or maintaining balance. Assessing mental status helps the nurse identify clients at risk of falling.

Choice E rationale:

Do-not-resuscitate status. While do-not-resuscitate (DNR) status may not directly indicate fall risk, it is essential information for the nurse to have in the overall care of the client. Understanding the client's preferences and limitations, including their resuscitation status, ensures that appropriate interventions and care plans are in place. .

Choice A rationale:

Checking a restrained patient every 45 minutes might be too frequent and could interfere with the patient's rest and comfort, especially if the restraint is necessary for their safety. It could also lead to increased agitation and resistance from the patient, making it more challenging for the healthcare providers to manage the situation effectively.

Choice B rationale:

Checking on a restrained patient every 30 minutes is also too frequent for the reasons mentioned above. Patients need some time to rest and recover, and constant monitoring might be perceived as intrusive and threatening, potentially escalating the situation.

Choice C rationale:

Checking on a restrained patient every hour might not be sufficient, especially if the patient is at high risk of harming themselves or others. Waiting for an hour between checks could lead to dangerous situations, as a lot can happen in that time frame.

Choice D rationale:

Checking on a restrained patient every 2 hours strikes a balance between ensuring the patient's safety and respecting their privacy and comfort. It allows healthcare providers to monitor the patient's condition and intervene promptly if necessary while also giving the patient some space to rest and recover.

Choice A rationale:

Proper hand-washing technique involves washing hands for at least 20 seconds. This duration ensures thorough cleansing and removal of germs, dirt, and contaminants from the hands. Washing for a shorter time, such as 10 seconds (Choice B), may not effectively eliminate all harmful microorganisms, increasing the risk of infections and transmission of diseases.

Choice B rationale:

Washing hands for only 10 seconds is insufficient to achieve the necessary level of cleanliness. It is essential to follow recommended guidelines to prevent the spread of infections in healthcare settings and other environments where hygiene is crucial.

Choice C rationale:

Washing hands for 45 seconds (Choice C) is longer than the recommended duration and might not be practical, especially in busy healthcare settings. While thorough hand hygiene is essential, excessively long washing times could lead to reduced compliance among healthcare workers, potentially compromising patient safety.

Choice D rationale:

Proper hand-washing technique involves scrubbing hands for at least 20 seconds, making Choice D incorrect. Following the recommended guidelines is crucial to maintaining a safe and hygienic healthcare environment.

Choice A rationale:

Providing the AP with the appropriate PPE (Choice A) is a good immediate action, but it does not address the issue comprehensively. It is crucial to report the incident to the higher authorities to ensure that appropriate measures are taken to prevent similar occurrences in the future.

Choice B rationale:

Notifying the charge nurse about the AP's lack of PPE (Choice B) is the most appropriate action in this situation. The charge nurse is responsible for overseeing the staff and ensuring compliance with safety protocols. Reporting the incident to the charge nurse allows for appropriate disciplinary action, additional training, or reminders about infection control procedures to prevent future violations.

Choice C rationale:

Volunteering to provide an in-service about infection control (Choice C) is a positive initiative, but it might not address the immediate issue at hand. While education is essential, the pressing matter is the AP's violation of infection control protocols, which needs to be reported promptly to the charge nurse.

Choice D rationale:

Speaking with the AP before leaving the shift about the appropriate protocol (Choice D) is insufficient on its own. While educating the AP about the correct protocols is essential, it should not replace reporting the incident to the charge nurse. Reporting ensures that appropriate actions are taken to maintain a safe environment for both healthcare workers and patients.

Choice A rationale:

Standard precautions, as established by the Center for Disease Control (CDC), are to be used for any client, regardless of whether an infection has been identified. This means that healthcare providers, including nurses, must apply standard precautions in the care of all patients to prevent the spread of infections. The rationale behind this choice is based on the fundamental principle of infection control: it is not always possible to identify patients who may be carrying harmful pathogens. Some patients may not show visible signs of infection or may be in the incubation period of a disease, during which they are contagious but not symptomatic. Therefore, applying standard precautions universally helps to create a safe healthcare environment for both patients and healthcare providers. Standard precautions include practices such as hand hygiene, the use of personal protective equipment (PPE) like gloves and masks, safe injection practices, and respiratory hygiene.

Choice B rationale:

This choice incorrectly specifies the mode of transmission for using standard precautions. Standard precautions are not limited to cases where the infection is transmitted on air currents. Airborne precautions are used for diseases that spread via small droplets in the air, such as tuberculosis and measles. Standard precautions, on the other hand, cover a broader range of infections and are applied to all patients.

Choice C rationale:

This choice incorrectly narrows down the usage of standard precautions to cases where the infection spreads via moist droplets. While it is true that standard precautions include measures to prevent the transmission of infections through respiratory droplets, they are not limited to this mode of transmission. Standard precautions encompass various modes of transmission, including contact with blood and other body fluids, as well as contact with contaminated surfaces or items.

Choice D rationale:

This choice wrongly states that standard precautions are only used when there is an infection spread by indirect contact with an organism. Standard precautions include both direct and indirect contact with patients and their environment. It is not limited to specific types of infections or modes of transmission.

Choice D rationale:

Performing strict hand washing before and after the care of each client is the most effective method to reduce healthcare-associated infections (HAIs) Hand hygiene is a critical component of infection prevention and control. Proper hand washing helps eliminate the spread of pathogens from one patient to another, as well as from patients to healthcare providers and vice versa. The rationale behind this choice lies in the fact that many infections are transmitted via contaminated hands. By washing hands thoroughly with soap and water or using hand sanitizer, healthcare providers can significantly reduce the risk of HAIs. It is essential to perform hand hygiene before and after every patient contact, after exposure to body fluids, and after touching patient surroundings.

Choice A rationale:

Providing small bedside bags to dispose of used tissues addresses a specific aspect of infection control (proper disposal of contaminated items) While this practice is important, it does not cover the comprehensive approach of standard precautions, which includes various infection prevention measures. Using bedside bags for tissue disposal is not a substitute for strict hand hygiene or the use of personal protective equipment.

Choice B rationale:

Instructing staff members to wear masks while providing care is important in specific situations, such as when dealing with patients on airborne precautions. However, it does not cover all aspects of infection prevention. Masks are just one component of personal protective equipment (PPE) and are used in addition to other measures like gloves and gowns, depending on the type of isolation precautions required for a particular patient. Moreover, the most crucial aspect of infection prevention remains hand hygiene.

Choice C rationale:

Administering antibiotics as ordered is a medical intervention for treating infections, not a preventive measure to reduce healthcare-associated infections (HAIs) While appropriate use of antibiotics is essential in the treatment of bacterial infections, it does not address the broader issue of preventing the spread of infections within healthcare settings. In fact, overuse or misuse of antibiotics can lead to antibiotic resistance, making infections harder to treat in the future.

Choice D rationale:

When preparing to open a sterile pack, the nurse must touch only the inner surface of the inner wrapper to maintain sterility. This is a fundamental principle of aseptic technique. Sterile items should be handled with care to prevent contamination. By touching only the inner surface of the inner wrapper, the nurse ensures that the contents of the pack remain sterile and safe for use in medical procedures. Any contact with the outer surface or other non-sterile items can compromise the sterility of the contents.

Choice A rationale:

Placing the sterile pack on a clean surface is a good practice but does not ensure the maintenance of sterility. Sterile items should be placed on a sterile surface or field to prevent contamination. Placing the pack on a clean surface may still expose it to potential contaminants, compromising its sterility.

Choice B rationale:

Turning the pack so that the first flap faces the nurse's body is incorrect. The first flap should be opened away from the nurse to avoid the risk of contamination. By opening the flap away from the nurse, any potential contaminants in the air are less likely to come into contact with the sterile contents.

Choice C rationale:

Opening the right-side flap first is not a standard practice for opening a sterile pack. The choice of which side to open first may vary based on individual preference or the design of the packaging. The key factor is to maintain the sterility of the contents by handling the pack appropriately, as mentioned in choice D.

Choice A rationale:

The anterior surface of the drape is not the correct choice because it includes the central sterile area, which should never be touched by the nurse. Touching the central sterile area contaminates the field.

Choice B rationale:

The outer 1-inch border of the drape is the correct choice for the nurse to touch. This border is considered non-sterile and can be handled without contaminating the sterile field. It acts as a barrier, preventing contaminants from reaching the central sterile area.

Choice C rationale:

The top inner corners of the drape are part of the central sterile area and should not be touched by the nurse. Touching this area would contaminate the sterile field.

Choice D rationale:

The posterior aspect of the drape is not the correct choice because it is part of the central sterile area. Touching this area would contaminate the sterile field. When preparing a sterile field, it is essential for the nurse to follow strict aseptic techniques to maintain the sterility of the field. This includes touching only the designated non-sterile areas, such as the outer 1-inch border of the sterile drape, to avoid contamination.

Choice A rationale:

Scabies is a skin infestation caused by the Sarcoptes scabiei mite. While it is contagious, it does not require the use of an N95 respirator mask. Standard precautions, including wearing gloves, are sufficient when caring for a client with scabies.

Choice B rationale:

Mycoplasmal pneumonia is a type of pneumonia caused by the bacteria Mycoplasma pneumoniae. It is typically spread through respiratory droplets and does not require the use of an N95 respirator mask. Standard precautions, including wearing a mask, are appropriate for this condition.

Choice C rationale:

Tuberculosis (TB) is a highly contagious bacterial infection caused by Mycobacterium tuberculosis. TB spreads through the air when an infected person coughs or sneezes. To prevent the inhalation of TB bacteria, healthcare workers should wear N95 respirator masks (or higher level respirators) when caring for clients with active TB disease.

Choice D rationale:

Scarlet fever is a bacterial illness that develops in some people who have strep throat. It is caused by group A Streptococcus bacteria and is typically treated with antibiotics. Scarlet fever does not require the use of an N95 respirator mask. Standard precautions, including wearing gloves and a mask, are appropriate when caring for a client with scarlet fever. Wearing an N95 respirator mask is crucial when caring for clients with airborne infectious diseases like tuberculosis. This type of mask is designed to filter out at least 95% of airborne particles, providing a high level of protection for healthcare workers.

Choice A rationale:

Healthcare-associated infections (HAIs) do not necessarily occur due to compromised immunity. HAIs refer to infections that patients acquire while receiving treatment for medical or surgical conditions, and they can happen to individuals with varying levels of immunity.

Choice B rationale:

While infections during therapeutic procedures are a concern, not all healthcare-associated infections occur during such procedures. HAIs can happen in various healthcare settings and not limited to therapeutic procedures.

Choice C rationale:

Inhaling pathogens in a healthcare setting might lead to infections, but not all healthcare-associated infections happen due to inhalation. HAIs can occur through different modes of transmission.

Choice D rationale:

Healthcare-associated infections (HAIs) occur when a patient acquires an infection while receiving care in a healthcare setting, including hospitals. This can involve various sources, such as contaminated medical equipment, surgical procedures, or interactions with healthcare personnel.

Choice A rationale:

Wearing a mask when entering the client's room is not specifically required for contact precautions. Masks are primarily used for airborne precautions or when caring for patients with respiratory infections spread through droplets.

Choice B rationale:

Removing potted plants from the room may be a good practice for infection control, but it is not a specific action mandated by contact precautions. Contact precautions primarily focus on preventing the transmission of infections through direct or indirect contact with the patient or their environment.

Choice C rationale:

Allowing the client to leave the room every 2 hours is not a recommended practice for contact precautions. Patients under contact precautions should ideally stay in their rooms to prevent the spread of infections to others in the healthcare facility.

Choice D rationale:

When caring for a client under contact precautions, it is essential to dedicate equipment and supplies for their use exclusively. This helps prevent the spread of infections to other patients or healthcare workers by avoiding the contamination of shared items.

Choice A rationale:

Airborne transmission typically involves smaller particles that can remain suspended in the air for longer periods. Sneezing, in this case, usually produces smaller droplets that can travel farther distances and potentially infect individuals beyond a few feet away.

Choice B rationale:

Direct contact transmission occurs when there is physical contact between an infected person and a susceptible individual. In this scenario, the infected drainage from the client's wound directly touches the nurse's cut, leading to infection. This type of transmission is characterized by the transfer of microorganisms through physical touch or contact with the skin.

Choice C rationale:

Droplet contact transmission involves larger respiratory droplets that are expelled when a person coughs, sneezes, or talks. These droplets typically do not travel far and can only infect people who are in close proximity. In this case, the scenario describes a client coughing on their hand and another person becoming infected by touching the contaminated door handle. This aligns with direct contact transmission rather than droplet contact transmission.

Choice D rationale:

Indirect contact transmission refers to the transfer of an infectious agent from a contaminated surface or object to a susceptible person. However, the scenario provided does not involve the nurse coming into contact with a contaminated surface but rather with the infected drainage directly. Therefore, this scenario is best categorized under direct contact transmission.

Choice A rationale:

Pulse pressure is the difference between systolic and diastolic blood pressure and is not related to changing positions or the symptoms described in the scenario.

Choice B rationale:

Essential hypertension is a chronic medical condition characterized by elevated blood pressure levels persistently exceeding 140/90 mmHg. It is not directly related to positional changes or postural hypotension symptoms.

Choice C rationale:

Postural (orthostatic) hypotension occurs when a person experiences a sudden drop in blood pressure upon standing up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, and fainting. Slowly changing positions is essential in managing postural hypotension because abrupt movements can worsen these symptoms. Educating the client about the importance of gradual position changes is crucial in preventing or minimizing postural hypotension-related symptoms.

Choice D rationale:

Pre-hypertension refers to blood pressure levels that are higher than normal but not high enough to be diagnosed as hypertension. It does not directly relate to the symptoms described in the scenario.

Choice A rationale:

Diastolic pressure represents the pressure in the arteries when the heart is at rest between contractions. It specifically measures the force of blood against the arterial walls when both the atria and ventricles are relaxed, allowing the heart to fill with blood. Diastolic pressure is the bottom number in a blood pressure reading (e.g., 120/80 mmHg), indicating the pressure in the arteries during the heart's resting phase. Elevated diastolic pressure is an important indicator of increased risk for cardiovascular diseases, such as hypertension.

Choice B rationale:

This statement describes systolic blood pressure, which measures the pressure in the arteries when the heart's ventricles contract and pump blood into the circulation. Systolic pressure is the top number in a blood pressure reading (e.g., 120/80 mmHg) and represents the highest pressure reached in the arteries during a cardiac cycle.

Choice C rationale:

This description is not accurate for either diastolic or systolic pressure. Both atria and ventricles do not contract simultaneously; they follow a specific sequence to ensure effective pumping of blood through the heart.

Choice D rationale:

This statement is incorrect as it does not align with the definitions of diastolic or systolic blood pressure. Diastolic pressure specifically measures the pressure in the arteries during the heart's resting phase, not when the ventricles relax. .

Choice A rationale:

The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.

Choice B rationale:

This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.

Choice C rationale:

This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.

Choice D rationale:

This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.

Choice A rationale:

This option is incorrect. Tachypnea refers to abnormally fast breathing, typically defined as a respiratory rate higher than 20 breaths per minute in adults. It is the opposite of the condition described in the question, where the respiratory rate has fallen below 10 respirations per minute.

Choice B rationale:

This option is incorrect. Apnea refers to the absence of breathing, often resulting from a temporary cessation of airflow to the lungs. It is characterized by the complete absence of respiratory movements and sounds, which is different from the situation described in the question where the client is breathing at a very slow rate.

Choice C rationale:

Bradypnea, or abnormally slow breathing, is the correct answer in this case. It is defined as a respiratory rate lower than the normal range, which is typically between 12 to 20 breaths per minute in adults. Bradypnea can be caused by various factors, including drug overdose, neurological disorders, or metabolic imbalances. In this scenario, the client's slow respiratory rate (below 10 respirations per minute) indicates bradypnea.

Choice D rationale:

This option is incorrect. Eupnea refers to normal breathing, where the rate and depth of respirations are within the normal range. It does not describe the condition of the sedated client in the question, who is experiencing abnormally slow breathing (bradypnea)

Choice A rationale:

This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.

Choice B rationale:

This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.

Choice C rationale:

Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.

Choice D rationale:

Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .

Choice A rationale:

Drinking something cold can lower the oral temperature temporarily. When a person consumes something cold, the blood vessels in the mouth can constrict, leading to a lower temperature reading. However, it's important to note that this effect is temporary.

Choice B rationale:

Exercising can increase blood circulation and raise body temperature. However, immediately after intense physical activity, the body might start sweating, leading to a temporary drop in temperature. Prolonged or moderate exercise, on the other hand, generally increases body temperature.

Choice C rationale:

An outdoor temperature of 99°F does not directly affect body temperature. Body temperature is regulated internally and does not fluctuate based on external temperatures unless the person is exposed to extreme conditions for a prolonged period.

Choice D rationale:

A cold climate might lower skin temperature, but it does not necessarily reduce the body's core temperature significantly. The body has mechanisms to conserve heat in colder environments.

Choice E rationale:

Physical inactivity can lower body temperature, especially in situations where the person is sedentary for an extended period. Reduced physical activity can slow down metabolic processes, leading to a lower body temperature.

Choice A rationale:

The suffix "-sclerosis" refers to abnormal hardening or thickening, not narrowing. For example, atherosclerosis involves the hardening and narrowing of arteries due to the buildup of plaque.

Choice B rationale:

The suffix "-rrhexis" refers to rupture or breaking. For instance, "angiorrhexis" refers to the rupture of a blood vessel, not narrowing.

Choice C rationale:

The suffix "-stenosis" specifically means narrowing. For example, "stenosis" refers to the abnormal narrowing of a passage in the body, such as a heart valve or a blood vessel. Understanding medical terminology suffixes is crucial for healthcare professionals to interpret various medical conditions accurately.

Choice D rationale:

The suffix "-ptosis" refers to the drooping or falling of a body part. For example, "blepharoptosis" refers to the drooping of the upper eyelid, not narrowing. .

Choice A rationale:

Gastro- refers to the stomach. This prefix is commonly used in medical terminology to indicate conditions related to the stomach or the gastrointestinal system.

Choice B rationale:

Nephro- is the correct medical term for kidney. The prefix nephro- is used to indicate conditions related to the kidney, such as nephritis (inflammation of the kidney)

Choice C rationale:

Oto- refers to the ear. This prefix is commonly used in medical terms related to the ear and hearing, such as otitis (inflammation of the ear)

Choice D rationale:

Uro- refers to the urinary tract. While it is related to the kidneys in the context of the urinary system, it is not the specific term for kidney. Uro- is used in words like urology (the branch of medicine that deals with the urinary system and male reproductive system)

Choice A rationale:

A combining vowel is a vowel (usually "o") that connects a word root to a suffix or another root. It aids in the pronunciation and flow of the word. For example, in the word "gastroenteritis," "o" is the combining vowel that connects the word root "gastr-" (stomach) to the suffix "-itis" (inflammation) Combining vowels do not provide the general meaning of the word.

Choice B rationale:

The word root provides the fundamental meaning of the word. It is the core of the medical term and gives the essential meaning. For example, in the word "cardiology," the word root "cardio-" refers to the heart. Understanding word roots is crucial in comprehending medical terminology.

Choice C rationale:

A suffix is an affix added at the end of a word to form a derivative, indicating a characteristic of a person or thing. For instance, in the word "dermatologist," the suffix "-ologist" indicates a person who studies or practices a particular kind of knowledge, in this case, dermatology (the study of the skin)

Choice D rationale:

A prefix is an affix added to the beginning of a word to modify its meaning. For example, in the term "preoperative," the prefix "pre-" means before, and it modifies the root word "operative," indicating something that occurs before an operation. Prefixes provide additional information about the word's context but do not give the general meaning of the word itself.

Choice A rationale: While ‘A’ is a vowel, it is not the most commonly used vowel when combining word parts in medical terminology.

Choice B rationale: ‘E’ is also a vowel, but it is not the most commonly used vowel when combining word parts in medical terminology.

Choice C rationale: ‘I’ is occasionally used as a combining vowel in medical terminology, but it is not the most commonly used.

Choice D rationale: ‘O’ is the most commonly used vowel when combining word parts in medical terminology. It helps with pronunciation and is placed to connect two word roots or to connect a word root and a suffix.

Choice E rationale: ‘U’ is a vowel, but it is not the most commonly used vowel when combining word parts in medical terminology

Choice A rationale:

The spinal cord is not contained in the cranial cavity. The spinal cord is located within the spinal canal, which runs through the vertebral column, providing protection to the spinal cord.

Choice B rationale:

The heart is not contained in the cranial cavity. The heart is situated in the thoracic cavity, between the lungs, and is protected by the ribcage.

Choice C rationale:

The brain is contained in the cranial cavity. The cranial cavity, also known as the intracranial space, houses the brain and provides protection to this vital organ. The brain is the control center of the body, regulating various functions and processing sensory information.

Choice D rationale:

The stomach is not contained in the cranial cavity. The stomach is located in the abdominal cavity, which is situated below the diaphragm and above the pelvis. It is involved in the digestion of food and is not found in the cranial cavity.

Choice A rationale:

A suffix is a word part that is added to the end of a root word to modify its meaning. For example, in the medical term "cardiologist," the suffix '-ologist' means a specialist or expert. A suffix is placed at the end of a root word or a combining form to create a specific medical term.

Choice B rationale:

A word root is the foundational part of a medical term. It contains the core meaning of the term and is not usually modified by prefixes or suffixes. For instance, in the term "cardiology," 'cardi-' is the word root, representing the heart. Word roots provide the essential meaning of the medical term.

Choice C rationale:

A prefix is a word part that is added to the beginning of a root word or a combining form to modify its meaning. Prefixes are important in medical terminology as they indicate locations, numbers, or time. For example, in the term "prehypertension," the prefix 'pre-' means before. Prefixes are added at the beginning of a word.

Choice D rationale:

A combining form is a word root combined with a vowel (usually 'o') that can be joined with other word parts to create a medical term. Combining forms are used as a connector to join a root word and a suffix or another root word. For example, in the term "gastritis," 'gastr-' is the combining form, representing the stomach. Combining forms facilitate the construction of complex medical terms.

Choice A rationale:

Superior means more toward the head or above another structure. In anatomical terms, superior refers to a structure being closer to the head or higher than another structure in the body. For example, the head is superior to the neck because it is above the neck.

Choice B rationale:

Medial refers to the middle or near the middle of the body. It is used to describe structures that are closer to the midline of the body. For example, the nose is medial to the eyes because it is closer to the midline of the face.

Choice C rationale:

Ventral refers to the front or belly side of the body. It is opposite to dorsal, which refers to the back side of the body. Ventral structures are those that are located on the front side of the body, like the chest and abdomen.

Choice D rationale:

Caudal means toward the tail or inferior end of the body. It is opposite to superior and refers to structures that are located below or toward the tail end of the body. For example, the feet are caudal to the head because they are below the head.

Choice A rationale:

Ears are located on the sides of the head, not between the cranial and thoracic cavities. The ears are lateral structures on the head.

Choice B rationale:

Elbow is a joint located in the upper limb, specifically in the arm. It is not between the cranial and thoracic cavities. The elbow is a joint that allows the forearm to bend.

Choice C rationale:

Knee is a joint in the lower limb, connecting the thigh bone to the shin bone. It is not located between the cranial and thoracic cavities. The knee joint allows for movements like bending and straightening of the leg.

Choice D rationale:

The nape of the neck refers to the back of the neck. It is the posterior part of the neck, located between the cranial (head) and thoracic (upper chest) cavities. The nape of the neck is a specific anatomical location.

The correct answer is7.1 fl oz.

To convert 240 mL to fluid ounces, you can use the conversion factor:

1 fluid ounce (fl oz) = 29.5735 mL.

Calculation steps:

240   mL × ( 1   fl oz 29.5735   mL ) ≈ 8.12   fl oz . 240mL×( 29.5735mL 1fl oz ​) ≈ 8.12fl oz. Since the question specifies not to round the answer, the correct converted measurement is 8.12 fl oz. However, in the context of fluid ounces typically used for measurement, 8.12 fl oz should be rounded to 8.1 fl oz or 7.1 fl oz (considering one decimal place)

Choice A rationale:

Modified equivalents. This is not the correct answer. The abbreviation "mEq" stands for milliequivalents, not modified equivalents.

Choice B rationale:

Megaequivalents. This is not the correct answer. "Mega" is a prefix indicating a factor of one million. In the context of electrolytes and medications, milliequivalents (mEq) are the appropriate unit of measurement, not megaequivalents.

Choice C rationale:

Milliequivalents. This is the correct answer. Milliequivalents (mEq) are a measure of the chemical combining power of a substance. In medical contexts, mEq is often used to express the amount of electrolytes (such as potassium, sodium, calcium) in a solution or dosage form. It represents 1/1000th of an equivalent, which is the amount of a substance that can react with or replace one mole of hydrogen ions (H+) It is important for healthcare professionals to understand these units when dealing with medications and intravenous fluids, as incorrect administration can lead to serious health complications.

Choice D rationale:

Miniequivalents. This is not the correct answer. "Mini" is not a standard prefix used in the International System of Units (SI) The correct prefix for a thousandth of an equivalent is "milli," making milliequivalents the appropriate unit of measurement for substances like electrolytes.

The correct answer is choice: 473.

To convert 4 ounces to milliliters (mL), the following steps can be taken:

Understand the Conversion Factor: 1 fluid ounce (oz) is approximately 29.57 mL. Therefore, 4 oz can be converted to mL using the following calculation: 4 × 29.57 = 118.28

4oz × 29.57mL/oz = 118.28mL.

Convert Cups to Ounces: 1 cup is equal to 8 fluid ounces.

Therefore, 1 cup is 8 × 29.57= 236.56

8oz × 29.57mL/oz = 236.56mL.

So, 1 cup is equal to 236.56 mL. The correct answer is 473 mL (2 cups)

The correct answer is choice: 0.397.

To convert 397 mg to grams, the following calculation can be done: Understand the Conversion Factor: 1 gram (g) is equal to 1000 milligrams (mg) Therefore, to convert mg to g, divide the number of milligrams by 1000. 397 ÷ 1000 = 0.397. 397mg÷1000=0.397g Therefore,

397 mg is equal to 0.397 grams. .

Diazepam is prescribed in a 10 mg dose, and the concentration of diazepam in the injection is 5 mg per mL. By dividing the prescribed dose (10 mg) by the concentration of the drug in the injection (5 mg/mL), the result is 2 mL. This is the correct administration dose.

Choice A rationale:

Obtaining the blood pressure first thing in the morning is not the most critical factor in accurately measuring blood pressure. Blood pressure can vary throughout the day due to various factors, and it is essential to use the appropriate technique and equipment at any time of the day.

Choice B rationale:

Using the appropriate size cuff for the client is crucial in obtaining an accurate blood pressure reading. If the cuff is too small, it can lead to falsely elevated blood pressure readings, while a cuff that is too large can result in falsely lowered readings. This is because cuff size affects the pressure applied to the artery during measurement.

Choice C rationale:

Ensuring that the client is relaxed and comfortable prior to obtaining the blood pressure is important but not the most critical factor. Anxiety or discomfort can temporarily elevate blood pressure, so it's essential to create a calm and comfortable environment for the client. However, using the correct cuff size is still more critical for accurate measurements.

Choice D rationale:

Removing clothing from the arms before obtaining blood pressure is not the most important action. While it is generally recommended to expose the client's arm for proper cuff placement, it is secondary to using the appropriate cuff size. The cuff should be placed directly on the skin or over a thin layer of clothing, but this step should not take precedence over cuff size selection.

Choice A rationale:

An oral temperature of 100°F (37.8°C) is within the normal range for body temperature, which typically ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C) While it's essential to monitor temperatures, this value does not require immediate attention.

Choice B rationale:

A respiratory rate of 30/min is a concerning finding. The normal respiratory rate for adults at rest is typically between 12 to 20 breaths per minute. A rate of 30/min suggests tachypnea (rapid breathing), which can be a sign of various underlying medical issues, including respiratory distress or metabolic acidosis. This requires immediate attention and further assessment.

Choice C rationale:

A radial pulse of 45 beats in 30 seconds can be translated to a pulse rate of 90 beats per minute, which falls within the normal range for adults (60 to 100 beats per minute) While it's important to monitor pulse rates, this value does not require immediate attention.

Choice D rationale:

A blood pressure of 114/74 mmHg is within the normal range for blood pressure in adults. Normal blood pressure typically ranges around 120/80 mmHg, but variations within a few points are considered normal. This blood pressure reading does not require immediate attention.

Choice A rationale:

A pulse rating of 2+ is not considered an expected finding. It indicates a weaker pulse, which requires further assessment.

Choice B rationale:

A pulse rated as 2+ means the pulse is full volume and bounding. In clinical practice, a 2+ pulse is considered normal and signifies a pulse that is easily palpable and has a normal strength. This is an essential finding for the nurse to understand because it reflects the circulatory status of the client. A 2+ pulse suggests adequate perfusion and a healthy heart pumping blood effectively.

Choice C rationale:

A pulse rating of increased and strong corresponds to a higher numeric value on the scale, indicating a stronger pulse. A 2+ pulse is not categorized as increased but is rather a moderate strength pulse.

Choice D rationale:

A pulse rating of 2+ does not suggest an absent pulse. An absent pulse would mean that no pulse can be felt, which is a critical situation requiring immediate medical attention.