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Questions 149

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Question 1 of 5

A 3-year-old child had a PPD skin test 2 days ago. When the mother brings the child back to the clinic to have the nurse check the results, the nurse notes a 10 mm area of induration. This is considered

Correct Answer: B

Rationale: A 10 mm induration 48-72 hours post-PPD is positive in children, indicating TB exposure, especially in high-risk groups.

Question 2 of 5

The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?

Correct Answer: C

Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.

Question 3 of 5

The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?

Correct Answer: C

Rationale: Halo traction is used for cervical fractures and can be maintained post-discharge for stabilization.

Question 4 of 5

The nurse is preparing to admit a client from the emergency department with tuberculosis. Which of the following should the nurse anticipate in caring for this client? Select all that apply.

Correct Answer: C, D, E, F

Rationale: Tuberculosis requires airborne precautions, standard precautions, negative airflow rooms, and N95/PAPR use due to respiratory transmission. Fall precautions are not specific, and droplet precautions are incorrect.

Question 5 of 5

The nurse is caring for a postpartum client 2 hours post-delivery who is unable to void. Which of the following nursing interventions should be considered initially?

Correct Answer: D

Rationale: Palpating the bladder assesses for distention, which may indicate urinary retention, guiding further interventions without immediately resorting to invasive measures.

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