Page 2196 - Saunders Comprehensive Review For NCLEX-RN

Answers

763. Answer: 2

Rationale: Gowns and gloves are required if the nurse anticipates contact with
soiled items such as those with wound drainage, or is caring for a client who is
incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are
not required unless droplet or airborne precautions are necessary. Regardless of the
amount of wound drainage, a gown and gloves must be worn.
Test-Taking Strategy: Focus on the subject, the method of transmission of
infection from Kaposi’s sarcoma. Read the question, noting the task that is presented;
in this case, it is bathing and changing linens. Eliminate option 3, because the
method of transmission is not respiratory. Eliminate options 1 and 4 because neither
provides adequate protection based on the method of transmission.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Planning
Content Area: Foundations of Care: Infection Control
Health Problem: Adult Health: Immune: Immunodeficiency Syndrome
Priority Concepts: Infection; Safety
Reference: Ignatavicius, Workman, Rebar (2018), pp. 418-419.

764. Answer: 1

Rationale: To help reduce fatigue in the client with systemic lupus erythematosus,
the nurse should instruct the client to sit whenever possible, avoid hot baths
(because they exacerbate fatigue), schedule moderate low-impact exercises when not
fatigued, and maintain a balanced diet. The client is instructed to avoid long periods
of rest because it promotes joint stiffness.
Test-Taking Strategy: Note the strategic words, need for further instruction. These
words indicate a negative event query and the need to select the incorrect client
statement. Also, focus on the subject, fatigue. This will assist in directing you to the
correct option as the action that would exacerbate fatigue.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health: Immune
Health Problem: Adult Health: Immune: Autoimmune Disease
Priority Concepts: Client Education; Immunity
Reference: Lewis et al. (2017), p. 1542.

765. Answer: 1, 2, 3

Rationale: An anaphylactic reaction requires immediate action, starting with
quickly assessing the client’s respiratory status. Although the PHCP and the Rapid
Response Team must be notified immediately, the nurse must stay with the client.

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