Nokea
A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?
- A. Apply appropriate signs outside and inside the room
- B. Apply a mask with a shield if there is a risk of fluid splash
- C. Wear a gown to change soiled linens from incontinence
- D. Have gloves on while handling bedpans with feces
Correct Answer: D
Rationale: The correct answer is to have gloves on while handling bedpans with feces. Hepatitis A is transmitted through the fecal-oral route, and using gloves during such direct contact with feces is crucial in preventing the transmission of the infection. Choice A is not directly related to infection control for hepatitis A. Choice B is more relevant to preventing droplet transmission rather than fecal-oral transmission. Choice C is important for preventing contact transmission from soiled linens but is not as directly related to the mode of transmission of hepatitis A as using gloves when handling feces.
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A client with diabetes mellitus has a blood glucose level of 350 mg/dL. Which of these actions should the nurse take first?
- A. Administer insulin as ordered
- B. Encourage the client to drink fluids
- C. Notify the healthcare provider
- D. Recheck the blood glucose level in 30 minutes
Correct Answer: A
Rationale: Administering insulin as ordered is the priority action when a client with diabetes mellitus has a blood glucose level of 350 mg/dL. Insulin helps to lower the high blood glucose level and prevent complications such as diabetic ketoacidosis. Encouraging the client to drink fluids may be beneficial but does not address the immediate need to lower the blood glucose level. Notifying the healthcare provider and rechecking the blood glucose level can be important steps but should come after administering insulin to address the high glucose level promptly.
A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?
- A. Changing the TPN tubing and solution every 24 hours
- B. Monitoring the TPN infusion rate closely
- C. Keeping the head of the bed elevated
- D. Ensuring the solution is at room temperature before infusing
Correct Answer: A
Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.
The client is being taught about precautions with Coumadin therapy. Which over-the-counter medication should the client be instructed to avoid?
- A. Non-steroidal anti-inflammatory drugs
- B. Cough medicines with guaifenesin
- C. Histamine blockers
- D. Laxatives containing magnesium salts
Correct Answer: A
Rationale: The correct answer is A: Non-steroidal anti-inflammatory drugs (NSAIDs). When a client is on Coumadin therapy, NSAIDs should be avoided because they can increase the risk of bleeding due to their antiplatelet effects. Choices B, C, and D are incorrect. Cough medicines with guaifenesin, histamine blockers, and laxatives containing magnesium salts do not have a significant interaction with Coumadin therapy that would necessitate avoidance.
An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. administer the medication in 2 separate injections
- B. give the medication in the ventrogluteal site
- C. call to get a smaller volume ordered
- D. check with the pharmacy for a liquid form of the medication
Correct Answer: A
Rationale: Administering the medication in 2 separate injections is the correct action. When the total volume of an injection is relatively large for a specific site, dividing it into smaller volumes and administering them separately is a safer practice to prevent discomfort, tissue damage, or absorption issues. Giving the medication in the ventrogluteal site can be appropriate for IM injections but does not address the issue of the total volume being too high for a single injection. Calling to get a smaller volume ordered may delay treatment and is not necessary when a safe administration method is available. Checking with the pharmacy for a liquid form of the medication does not directly address the issue of the total volume being too high for a single injection, and changing the formulation may not be necessary if the correct administration technique can be applied.
A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit?
- A. Boiled rice
- B. Italian bread
- C. Broiled salmon filet
- D. Pickled beets
Correct Answer: D
Rationale: The correct answer is D, Pickled beets. Pickled foods often contain high levels of sodium, which should be avoided in a low-sodium diet. Boiled rice, Italian bread, and broiled salmon filet are generally lower in sodium compared to pickled beets, making them more suitable choices for a client on a low-sodium diet.